Healthcare Provider Details

I. General information

NPI: 1386478352
Provider Name (Legal Business Name): CODY GENE STEVENSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SANDY SPRING RD
ZUNI NM
87327
US

IV. Provider business mailing address

10 SANDY SPRING RD
ZUNI NM
87327
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-5511
  • Fax:
Mailing address:
  • Phone: 505-782-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number272502
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: