Provider Demographics
NPI:1669995452
Name:STEVENSON, KACYLIA STALIN
Entity type:Individual
Prefix:
First Name:KACYLIA
Middle Name:STALIN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368015 OLD HIGHWAY 62
Mailing Address - Street 2:
Mailing Address - City:BOLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74829-2914
Mailing Address - Country:US
Mailing Address - Phone:405-436-8221
Mailing Address - Fax:
Practice Address - Street 1:368015 OLD HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829-2914
Practice Address - Country:US
Practice Address - Phone:405-436-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator