Provider Demographics
NPI:1821161522
Name:STEVENS, SCOTT G (OT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:G
Last Name:STEVENS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 DIANE LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1906
Mailing Address - Country:US
Mailing Address - Phone:208-234-9344
Mailing Address - Fax:
Practice Address - Street 1:4473 FOX CT
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2670
Practice Address - Country:US
Practice Address - Phone:208-234-9344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist