Provider Demographics
NPI:1467676254
Name:STEPHENSON, MACK B (PHD)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:B
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 SW 5TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2923
Mailing Address - Country:US
Mailing Address - Phone:208-288-0692
Mailing Address - Fax:208-288-0467
Practice Address - Street 1:78 SW 5TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2923
Practice Address - Country:US
Practice Address - Phone:208-288-0692
Practice Address - Fax:208-288-0467
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202056103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist