Healthcare Provider Details

I. General information

NPI: 1750921367
Provider Name (Legal Business Name): STEPHAN IAN BELASCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2020
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 MACKEY BRANCH DR.
CHATTANOOGA TN
37421
US

IV. Provider business mailing address

1360 MACKEY BRANCH DR
CHATTANOOGA TN
37421-3225
US

V. Phone/Fax

Practice location:
  • Phone: 423-322-2748
  • Fax:
Mailing address:
  • Phone: 423-443-3336
  • Fax: 423-464-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8047
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: