Provider Demographics
NPI:1275083693
Name:STEPHENSON, DRAKE MATTHEW
Entity Type:Individual
Prefix:
First Name:DRAKE
Middle Name:MATTHEW
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4644 BILLMAR ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2291
Mailing Address - Country:US
Mailing Address - Phone:616-350-4476
Mailing Address - Fax:
Practice Address - Street 1:21600 OXNARD ST STE 1800
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-7807
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other