Healthcare Provider Details

I. General information

NPI: 1417197666
Provider Name (Legal Business Name): LARRY CHARLES STEVENS, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2009
Last Update Date: 03/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N BEAVER ST
FLAGSTAFF AZ
86001-3103
US

IV. Provider business mailing address

711 N BEAVER ST
FLAGSTAFF AZ
86001-3103
US

V. Phone/Fax

Practice location:
  • Phone: 928-779-3783
  • Fax: 928-773-1150
Mailing address:
  • Phone: 928-779-3783
  • Fax: 928-773-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number1177
License Number StateAZ

VIII. Authorized Official

Name: DR. LARRY CHARLES STEVENS
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 928-779-3783