Healthcare Provider Details

I. General information

NPI: 1124162557
Provider Name (Legal Business Name): STEPHEN LON OKIYAMA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 KNOBCONE DR UNIT 202
LOVELAND CO
80538-5711
US

IV. Provider business mailing address

123 AYLESWORTH HL NW
FORT COLLINS CO
80523-0001
US

V. Phone/Fax

Practice location:
  • Phone: 310-954-7492
  • Fax:
Mailing address:
  • Phone: 970-491-3387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12716
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY12716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: