Provider Demographics
NPI:1639574742
Name:STEVENSON, MICKEY (HCP)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:HCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 ROBERT C BYRD DRIVER
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-255-3113
Mailing Address - Fax:513-332-9042
Practice Address - Street 1:3140 ROBERT C BYRD DRIVER
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-3113
Practice Address - Fax:513-332-9042
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY211373237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist