Provider Demographics
NPI:1912089103
Name:STEVENS, MOLLY ANNE (DC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 PHILLIPS LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2537
Mailing Address - Country:US
Mailing Address - Phone:805-543-8688
Mailing Address - Fax:
Practice Address - Street 1:1428 PHILLIPS LN
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2537
Practice Address - Country:US
Practice Address - Phone:805-543-8688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC29936AMedicare ID - Type Unspecified