Provider Demographics
NPI:1871194274
Name:STEPHENS, LUCRETIUS D (DDP)
Entity Type:Individual
Prefix:
First Name:LUCRETIUS
Middle Name:D
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-7822
Mailing Address - Country:US
Mailing Address - Phone:706-992-6330
Mailing Address - Fax:
Practice Address - Street 1:3301 13TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7822
Practice Address - Country:US
Practice Address - Phone:706-992-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 251J00000X, 251S00000X, 253Z00000X, 261QM0850X, 343800000X, 343900000X, 251E00000X
GA903667039261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA903776039Medicaid
GA903667039Medicaid