Provider Demographics
NPI:1679591465
Name:VERNON, STEPHEN ADAIR (MFT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ADAIR
Last Name:VERNON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SOLANO AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1854
Mailing Address - Country:US
Mailing Address - Phone:510-528-8814
Mailing Address - Fax:510-528-8814
Practice Address - Street 1:1320 SOLANO AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1854
Practice Address - Country:US
Practice Address - Phone:510-528-8814
Practice Address - Fax:510-528-8814
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19830106H00000X
ORT0295106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01674804Medicaid