Provider Demographics
NPI:1467476150
Name:STEPHENS, TEDD A (EDD)
Entity Type:Individual
Prefix:
First Name:TEDD
Middle Name:A
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4644
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-4644
Mailing Address - Country:US
Mailing Address - Phone:423-928-1379
Mailing Address - Fax:423-928-1379
Practice Address - Street 1:2112 N ROAN ST FL 6
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2519
Practice Address - Country:US
Practice Address - Phone:423-928-1379
Practice Address - Fax:423-928-1379
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001029103TC0700X
TNCMT0000000186103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3688713Medicaid
TN3688713Medicare ID - Type Unspecified