MEDICARE: STEPHEN PHILLIP DEMIEN LMFT

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	106H00000X	Marriage & Family Therapist	166000620	IL

General Provider Information

NPI Number	:	1376095927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN PHILLIP DEMIEN LMFT

Provider Business Mailing Address
First Line	:	2440 NEW YORK AVE APT B
Second Line	:
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-2217
Country	:	US
Telephone Number	:	254-247-8497
Fax Number	:

Provider Business Practice Location Address
First Line	:	2440 NEW YORK AVE APT B
Second Line	:
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-2217
Country	:	US
Telephone Number	:	254-247-8497
Fax Number	:

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

Provider Enumeration Date	:	10/31/2016
Last Update Date	:	10/31/2016

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