Provider Demographics
NPI:1447371976
Name:STEVENS, LARRY CHARLES (PHD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:CHARLES
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3103
Mailing Address - Country:US
Mailing Address - Phone:928-779-3783
Mailing Address - Fax:928-773-1150
Practice Address - Street 1:711 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3103
Practice Address - Country:US
Practice Address - Phone:928-779-3783
Practice Address - Fax:928-773-1150
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1177103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPHD1177Medicare ID - Type UnspecifiedPSYCHOLOGIST