Provider Demographics
NPI:1447990585
Name:CHAVIS, STEFEN B
Entity type:Individual
Prefix:
First Name:STEFEN
Middle Name:B
Last Name:CHAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2569
Mailing Address - Country:US
Mailing Address - Phone:410-300-3949
Mailing Address - Fax:
Practice Address - Street 1:12164 TECH RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1914
Practice Address - Country:US
Practice Address - Phone:240-913-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-22-208412106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD775688OtherBCAB NUMBER