Provider Demographics
NPI:1417197666
Name:LARRY CHARLES STEVENS, PH.D., P.C.
Entity Type:Organization
Organization Name:LARRY CHARLES STEVENS, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-779-3783
Mailing Address - Street 1:711 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3103
Mailing Address - Country:US
Mailing Address - Phone:928-779-3783
Mailing Address - Fax:928-773-1150
Practice Address - Street 1:711 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3103
Practice Address - Country:US
Practice Address - Phone:928-779-3783
Practice Address - Fax:928-773-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-01
Last Update Date:2009-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1177103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPHD1177Medicare UPIN