Basic Information
| Provider Information | |||||||||
| NPI: | 1497934103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENSON | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 BROADWAY APT A220 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840255617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015771602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 466 N MAIN ST | ||||||||
| Address2: | 210 | ||||||||
| City: | CLEARFIELD | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840153222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017737060 | ||||||||
| FaxNumber: | 8017746100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2007 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 293249-6004 | UT | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 293249-3503 | UT | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | 293249-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.