Provider Demographics
NPI:1629070438
Name:STEVENS, FREDERICK LECOMPTE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:LECOMPTE
Last Name:STEVENS
Suffix:JR
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 1:1401 SE GOLDTREE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7584
Mailing Address - Country:US
Mailing Address - Phone:772-398-4377
Mailing Address - Fax:772-905-8526
Practice Address - Street 1:1401 SE GOLDTREE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7584
Practice Address - Country:US
Practice Address - Phone:772-398-4377
Practice Address - Fax:772-905-8526
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4177103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73470Medicare ID - Type Unspecified