MEDICARE: DR. EDWARD ELSWORTH STEVENSON JR. 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	005156-1	NY

General Provider Information

NPI Number	:	1356569164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD ELSWORTH STEVENSON JR. PH. D.

Provider Business Mailing Address
First Line	:	137 PUTNAM AVE
Second Line	:
City	:	FREEPORT
State	:	NY
Zip	:	11520-1151
Country	:	US
Telephone Number	:	516-868-2583
Fax Number	:	516-868-6253

Provider Business Practice Location Address
First Line	:	137 PUTNAM AVE
Second Line	:
City	:	FREEPORT
State	:	NY
Zip	:	11520-1151
Country	:	US
Telephone Number	:	516-868-2583
Fax Number	:	516-868-6253

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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