Provider Demographics
NPI:1407240997
Name:STEVENS, GEORGE JR
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:STEVENS
Suffix:JR
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 1:142 HIGH ST
Mailing Address - Street 2:SUITE 416
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 HIGH ST
Practice Address - Street 2:SUITE 416
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2851
Practice Address - Country:US
Practice Address - Phone:207-780-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5635101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)