Provider Demographics
NPI:1760582506
Name:MAYVILLE, STEPHEN BRADLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:BRADLEY
Last Name:MAYVILLE
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:PO BOX 70711
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89570-0711
Mailing Address - Country:US
Mailing Address - Phone:775-826-6218
Mailing Address - Fax:775-826-6271
Practice Address - Street 1:10631 PROFESSIONAL CIR
Practice Address - Street 2:STE. A
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5848
Practice Address - Country:US
Practice Address - Phone:775-826-6218
Practice Address - Fax:775-826-6271
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0477103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506484Medicaid
NV101241Medicare PIN