=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376908525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C. STEVENS PSYCHOLOGICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2015
-----------------------------------------------------
Last Update Date | 12/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1290 HIGHWAY A1A SUITE 208
-----------------------------------------------------
City | SATELLITE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32937-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-777-9961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1290 HIGHWAY A1A SUITE 208
-----------------------------------------------------
City | SATELLITE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32937-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-777-9961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHARLES STEVENS
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 321-777-9961
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PY4176
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------