Provider Demographics
NPI:1700138351
Name:STEVENSON, PORTIA ROCHELLE
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:ROCHELLE
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 1:3661 W SHIELDS AVE
Mailing Address - Street 2:#125
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6579
Mailing Address - Country:US
Mailing Address - Phone:559-708-5570
Mailing Address - Fax:
Practice Address - Street 1:3661 W SHIELDS AVE
Practice Address - Street 2:#125
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-6579
Practice Address - Country:US
Practice Address - Phone:559-708-5570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)