Provider Demographics
NPI:1245355361
Name:STEPHENS, CHARLES LUCAS (LMLP, LCP)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LUCAS
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:LMLP, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-2037
Mailing Address - Country:US
Mailing Address - Phone:316-283-1950
Mailing Address - Fax:316-283-9540
Practice Address - Street 1:11200 LARIAT WAY
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-7328
Practice Address - Country:US
Practice Address - Phone:620-225-0276
Practice Address - Fax:620-225-0276
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0141103T00000X, 103TP2701X
KS0136103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy