Provider Demographics
NPI:1790824381
Name:STEVENS, THEODORE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:M
Last Name:STEVENS
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 1:3076 BRICKHOUSE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6859
Mailing Address - Country:US
Mailing Address - Phone:757-486-0909
Mailing Address - Fax:757-340-7518
Practice Address - Street 1:3076 BRICKHOUSE CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6859
Practice Address - Country:US
Practice Address - Phone:757-486-0909
Practice Address - Fax:757-340-7518
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000970103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007788461Medicaid
VA620000201Medicare ID - Type Unspecified
VA007788461Medicaid