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General NPI Number Information
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NPI Number | 1093860561
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Entity Type | Organization
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Legal Business Name | MACK B. STEPHENSON, PH.D., CHTD
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 78 SW 5TH AVE SUITE 2
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City | MERIDIAN
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State | ID
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Zip | 83642-2923
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Country | US
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Telephone | 208-288-0692
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Fax | 208-288-0467
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Provider Business Mailing Address
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Address Line | 78 SW 5TH AVE SUITE 2
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City | MERIDIAN
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State | ID
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Zip | 83642-2923
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Country | US
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Telephone | 208-288-0692
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Fax | 208-288-0467
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Authorized Official
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Title or Position | PRESIDENT
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Name | MACK B. STEPHENSON
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Credential | PH.D.
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Telephone | 208-288-0692
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY-202056
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License Number State | ID
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