Healthcare Provider Details

I. General information

NPI: 1629414735
Provider Name (Legal Business Name): TERESA STEVENSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 CALIFORNIA HIGHWAY 104
IONE CA
95640
US

IV. Provider business mailing address

9102 GENERATIONS DR
ELK GROVE CA
95758-1202
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-4911
  • Fax:
Mailing address:
  • Phone: 310-903-9620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY13847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: