Provider Demographics
NPI:1104881051
Name:STEVENS, MARY (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 YORK AVE S
Mailing Address - Street 2:SUITE 161
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4450
Mailing Address - Country:US
Mailing Address - Phone:652-921-9964
Mailing Address - Fax:
Practice Address - Street 1:7101 YORK AVE S
Practice Address - Street 2:SUITE 161
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4450
Practice Address - Country:US
Practice Address - Phone:652-921-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0970103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16890STOtherBLUE CROSS
MN476347500Medicaid
MN16890STOtherBLUE CROSS
MNR35534Medicare UPIN