Provider Demographics
NPI:1710104195
Name:STEVENSON, JODY LYNN (LMSW CC)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:LYNN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LMSW CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0936
Mailing Address - Country:US
Mailing Address - Phone:207-945-4240
Mailing Address - Fax:207-990-3660
Practice Address - Street 1:970 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2722
Practice Address - Country:US
Practice Address - Phone:207-945-4240
Practice Address - Fax:207-990-3660
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC71551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical