Provider Demographics
NPI:1871960112
Name:CLEVENGER, MARION STEPHEN
Entity type:Individual
Prefix:MR
First Name:MARION
Middle Name:STEPHEN
Last Name:CLEVENGER
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 1:223 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1517
Mailing Address - Country:US
Mailing Address - Phone:636-288-7096
Mailing Address - Fax:
Practice Address - Street 1:1085 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1955
Practice Address - Country:US
Practice Address - Phone:573-756-5353
Practice Address - Fax:573-756-4557
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015034337101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015034337Medicaid