Provider Demographics
NPI:1558415034
Name:STEPHENSON, DIANE (PH D)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 ONTARIO ST
Mailing Address - Street 2:APT 3C
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1938
Mailing Address - Country:US
Mailing Address - Phone:708-302-5716
Mailing Address - Fax:
Practice Address - Street 1:1101 LAKE ST
Practice Address - Street 2:STE 405H
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1071
Practice Address - Country:US
Practice Address - Phone:708-524-9513
Practice Address - Fax:630-604-1115
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004319103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211127Medicare ID - Type Unspecified