Provider Demographics
NPI:1831736420
Name:STEVENS, DAWN MARIE
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:ILACQUA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 ROUTE 111
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3754
Mailing Address - Country:US
Mailing Address - Phone:631-920-8303
Mailing Address - Fax:631-920-8463
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3754
Practice Address - Country:US
Practice Address - Phone:631-920-8303
Practice Address - Fax:631-920-8463
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator