Provider Demographics
NPI:1255129243
Name:STEPHENS, SIDNEY GENE JR (SUDRC)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:GENE
Last Name:STEPHENS
Suffix:JR
Gender:
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1088
Mailing Address - Country:US
Mailing Address - Phone:510-346-7836
Mailing Address - Fax:
Practice Address - Street 1:2035 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94578-1088
Practice Address - Country:US
Practice Address - Phone:510-346-7836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21270101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)