Provider Demographics
NPI:1104992973
Name:FOSS, STEPHEN EUGENE (LMFT)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:EUGENE
Last Name:FOSS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 PEACE HAVEN RD # 201
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4850
Mailing Address - Country:US
Mailing Address - Phone:336-287-3843
Mailing Address - Fax:
Practice Address - Street 1:2735 HENNING DR STE A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106
Practice Address - Country:US
Practice Address - Phone:800-388-9804
Practice Address - Fax:336-794-0505
Is Sole Proprietor?:No
Enumeration Date:2006-11-25
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC821106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105009Medicaid