Provider Demographics
NPI:1376887315
Name:STEPHENS, RONNY W (LMHC,CAP)
Entity Type:Individual
Prefix:MR
First Name:RONNY
Middle Name:W
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:LMHC,CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3292 COUNTY ROAD 220
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-4357
Mailing Address - Country:US
Mailing Address - Phone:904-291-5561
Mailing Address - Fax:904-291-5675
Practice Address - Street 1:1726 KINGSLEY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4463
Practice Address - Country:US
Practice Address - Phone:904-278-5644
Practice Address - Fax:904-278-5659
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YA0400X
FLMH 12441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6449Medicaid