Provider Demographics
NPI:1780127241
Name:ILLERS, STEVEN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:ILLERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3854 HEATHER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-3844
Mailing Address - Country:US
Mailing Address - Phone:805-868-7581
Mailing Address - Fax:
Practice Address - Street 1:3854 HEATHER AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-3844
Practice Address - Country:US
Practice Address - Phone:702-219-0881
Practice Address - Fax:928-774-2159
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8122828385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child