MEDICARE: DR. STEPHEN C MCCONNELL PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2838	OH

General Provider Information

NPI Number	:	1427059492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN C MCCONNELL PHD

Provider Business Mailing Address
First Line	:	1020 WOODMAN DRIVE
Second Line	:	SUITE 300
City	:	DAYTON
State	:	OH
Zip	:	45432
Country	:	US
Telephone Number	:	937-424-0617
Fax Number	:	937-424-0632

Provider Business Practice Location Address
First Line	:	1020 WOODMAN DRIVE
Second Line	:	SUITE 300
City	:	DAYTON
State	:	OH
Zip	:	45432
Country	:	US
Telephone Number	:	937-424-0617
Fax Number	:	937-424-0632

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	03/23/2012

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