Provider Demographics
NPI:1336269398
Name:STEVENS, MARK WILLIAMS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAMS
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13525 MIDLAND RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-4771
Mailing Address - Country:US
Mailing Address - Phone:858-207-8322
Mailing Address - Fax:858-748-8050
Practice Address - Street 1:13525 MIDLAND RD
Practice Address - Street 2:SUITE J
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-4771
Practice Address - Country:US
Practice Address - Phone:858-207-8322
Practice Address - Fax:858-748-8050
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical