Provider Demographics
NPI:1609095454
Name:DEHAVEN, STEPHAN MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:MARK
Last Name:DEHAVEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 CENTERVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55127-6344
Mailing Address - Country:US
Mailing Address - Phone:651-429-3015
Mailing Address - Fax:651-653-3832
Practice Address - Street 1:1060 CENTERVILLE CIR
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-6344
Practice Address - Country:US
Practice Address - Phone:651-429-3015
Practice Address - Fax:651-653-3832
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2585111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN59969DEOtherMINNESOTA