Provider Demographics
NPI:1063758274
Name:STEPHENS, MICHAEL (MFT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:PALO CEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:96073-0445
Mailing Address - Country:US
Mailing Address - Phone:925-330-3621
Mailing Address - Fax:
Practice Address - Street 1:3191 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2123
Practice Address - Country:US
Practice Address - Phone:530-224-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42307106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist