Provider Demographics
NPI:1558795500
Name:STEGMAN, RUSSELL SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:SCOTT
Last Name:STEGMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-2232
Mailing Address - Country:US
Mailing Address - Phone:316-500-5419
Mailing Address - Fax:316-260-8993
Practice Address - Street 1:1009 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-2232
Practice Address - Country:US
Practice Address - Phone:316-500-5419
Practice Address - Fax:316-260-8993
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2394101YM0800X
390200000X
KS2550103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program