=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174881585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT L. STEVENS LADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2012
-----------------------------------------------------
Last Update Date | 04/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 S MERIDIAN AVE 525
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73108-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-627-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 334
-----------------------------------------------------
City | WHEATLAND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73097-0334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-627-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 2
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------