Healthcare Provider Details

I. General information

NPI: 1770833600
Provider Name (Legal Business Name): MS. EVON DENISE STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 SPENCER ST
LAS VEGAS NV
89119-9303
US

IV. Provider business mailing address

4045 S BUFFALO DR # A101-294
LAS VEGAS NV
89147-7479
US

V. Phone/Fax

Practice location:
  • Phone: 702-799-9710
  • Fax: 702-799-9712
Mailing address:
  • Phone: 702-326-4438
  • Fax: 702-473-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: