Provider Demographics
NPI:1366038713
Name:STEVENSON, MISTY DAWN (LICSW)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 OLD HUNTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-6015
Mailing Address - Country:US
Mailing Address - Phone:931-993-7081
Mailing Address - Fax:
Practice Address - Street 1:163 OLD HUNTSVILLE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-6015
Practice Address - Country:US
Practice Address - Phone:931-993-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4564C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical