=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629515259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRITTANY STEVENSON M.A., L.C.P.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2017
-----------------------------------------------------
Last Update Date | 01/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11601 S NAGLE AVE
-----------------------------------------------------
City | WORTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60482-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-921-4203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11601 S NAGLE AVE
-----------------------------------------------------
City | WORTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60482-2311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-921-4203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180010784
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------