Provider Demographics
NPI:1457705600
Name:STEPHENS, LARRY DANIEL (PHD, PCC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DANIEL
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:PHD, PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 SHADY OAK ST
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4238
Mailing Address - Country:US
Mailing Address - Phone:937-235-2244
Mailing Address - Fax:
Practice Address - Street 1:407 CORPORATE CENTER DR
Practice Address - Street 2:SUITE # D.
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1165
Practice Address - Country:US
Practice Address - Phone:937-750-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101130101YA0400X
OHE0004407101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)