Provider Demographics
NPI:1740395920
Name:STEVENSON, JOHN MARK SR (HAD-F)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARK
Last Name:STEVENSON
Suffix:SR
Gender:M
Credentials:HAD-F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 N MARIETTA PKWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8023
Mailing Address - Country:US
Mailing Address - Phone:770-590-8662
Mailing Address - Fax:
Practice Address - Street 1:145 N MARIETTA PKWY
Practice Address - Street 2:SUITE E
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8023
Practice Address - Country:US
Practice Address - Phone:770-590-8662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2124237700000X
GAHADS000963237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA035185274OtherDL