Healthcare Provider Details

I. General information

NPI: 1104092501
Provider Name (Legal Business Name): STEPHEN ROBERT HILLIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7810 BALLANTYNE COMMONS PKWY SUITE 300
CHARLOTTE NC
28277-3415
US

IV. Provider business mailing address

7810 BALLANTYNE COMMONS PKWY SUITE 300
CHARLOTTE NC
28277-3415
US

V. Phone/Fax

Practice location:
  • Phone: 703-319-2223
  • Fax: 704-319-2250
Mailing address:
  • Phone: 703-319-2223
  • Fax: 704-319-2250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1673
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1673
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: