Provider Demographics
NPI:1811269855
Name:STEPHENS, FRED WESLEY JR (LCSW)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:WESLEY
Last Name:STEPHENS
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7754A HEALDSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3352
Mailing Address - Country:US
Mailing Address - Phone:707-823-3201
Mailing Address - Fax:
Practice Address - Street 1:144 STONY POINT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4122
Practice Address - Country:US
Practice Address - Phone:707-521-4502
Practice Address - Fax:707-521-4628
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA157581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical