Healthcare Provider Details

I. General information

NPI: 1982914644
Provider Name (Legal Business Name): EVONNE LANAE STEPHENSON M.S., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E MAIN ST
SALEM IL
62881-2933
US

IV. Provider business mailing address

600 E MAIN ST
SALEM IL
62881-2933
US

V. Phone/Fax

Practice location:
  • Phone: 618-740-0726
  • Fax: 618-740-0727
Mailing address:
  • Phone: 618-740-0726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180008660
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: