Provider Demographics
NPI:1518033778
Name:STEVENS, PHYLLIS ELLEN
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:ELLEN
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19305 WATER OAK DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-3154
Mailing Address - Country:US
Mailing Address - Phone:941-764-9241
Mailing Address - Fax:941-764-8775
Practice Address - Street 1:20020 VETERANS BLVD
Practice Address - Street 2:UNIT 2
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-2112
Practice Address - Country:US
Practice Address - Phone:941-764-9241
Practice Address - Fax:941-764-8775
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5261101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health