Provider Demographics
NPI:1497888606
Name:NIELSEN, STEVAN LARS (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEVAN
Middle Name:LARS
Last Name:NIELSEN
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 1:1526 WSC
Mailing Address - Street 2:BYU
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602
Mailing Address - Country:US
Mailing Address - Phone:801-422-3035
Mailing Address - Fax:801-422-0175
Practice Address - Street 1:1526 WSC, BYU
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-422-3035
Practice Address - Fax:801-422-0175
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT115238-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical