Provider Demographics
NPI:1417538943
Name:STEVENS, REGINALD
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:STEVENS
Suffix:
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 1:9703 QUIET BROOK LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3374
Mailing Address - Country:US
Mailing Address - Phone:202-460-9172
Mailing Address - Fax:
Practice Address - Street 1:611 EDGEWOOD ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-4261
Practice Address - Country:US
Practice Address - Phone:202-480-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS-315-734-237-7603747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant