Provider Demographics
NPI:1821647991
Name:STEVENS, SELENA (MHP)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MHP
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 547
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-0547
Mailing Address - Country:US
Mailing Address - Phone:651-775-9802
Mailing Address - Fax:844-364-7181
Practice Address - Street 1:6448 MAIN ST STE 1AND3
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-7068
Practice Address - Country:US
Practice Address - Phone:651-775-9802
Practice Address - Fax:844-364-7181
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health