Provider Demographics
NPI:1669462669
Name:LAWRENCE, STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:LAWRENCE
Suffix:
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 1:139 HAZARD AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4585
Mailing Address - Country:US
Mailing Address - Phone:860-745-8225
Mailing Address - Fax:860-749-5335
Practice Address - Street 1:139 HAZARD AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4585
Practice Address - Country:US
Practice Address - Phone:860-745-8225
Practice Address - Fax:860-749-5335
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT722103TC0700X
MA2316103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
C003558OtherCHAMPUS
CT06-0000722CT01OtherANTHEM BLUE SHIELD
C003558OtherCHAMPUS