Provider Demographics
NPI:1508929324
Name:STEVENS, SEAN EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:EDWARD
Last Name:STEVENS
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 1:4045 ILEX CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4854
Mailing Address - Country:US
Mailing Address - Phone:850-271-2178
Mailing Address - Fax:
Practice Address - Street 1:1103 FORTUNE AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1831
Practice Address - Country:US
Practice Address - Phone:850-769-6188
Practice Address - Fax:850-769-1261
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6478103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54727OtherBLUE CROSS BLUE SHIELD
FL54727Medicare ID - Type UnspecifiedMEDICARE