MEDICARE: DR. STEPHEN LON OKIYAMA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY12716	CA
2	103TC1900X	Counseling Psychologist
3	103T00000X	Psychologist	PSY12716	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	74310	OTHER	CA	MANAGED HEALTH NETWORK

General Provider Information

NPI Number	:	1124162557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN LON OKIYAMA PH.D.

Provider Business Mailing Address
First Line	:	123 AYLESWORTH HL NW
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-0001
Country	:	US
Telephone Number	:	970-491-3387
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 KNOBCONE DR UNIT 202
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-5711
Country	:	US
Telephone Number	:	310-954-7492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2007
Last Update Date	:	11/05/2012

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