Provider Demographics
NPI:1346397387
Name:CHESHIRE, STEPHEN LEANDER III (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LEANDER
Last Name:CHESHIRE
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 MAIN ST NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031
Mailing Address - Country:US
Mailing Address - Phone:505-916-0820
Mailing Address - Fax:
Practice Address - Street 1:2235 MAIN ST NE
Practice Address - Street 2:SUITE C
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-916-0820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002308103TC0700X
NM1251103TC0700X
NM0042103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000896816DMedicaid
GA277711000OtherMAGELLAN PROVIDER ID