Provider Demographics
NPI:1457585614
Name:STURDEVANT, ADAM MILES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:MILES
Last Name:STURDEVANT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 DOUSMAN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3003
Mailing Address - Country:US
Mailing Address - Phone:920-888-6868
Mailing Address - Fax:
Practice Address - Street 1:1049 DOUSMAN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3003
Practice Address - Country:US
Practice Address - Phone:920-888-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14358-130101YA0400X
WI3638-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)