Provider Demographics
NPI:1124162557
Name:OKIYAMA, STEPHEN LON (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LON
Last Name:OKIYAMA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 AYLESWORTH HL NW
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80523-0001
Mailing Address - Country:US
Mailing Address - Phone:970-491-3387
Mailing Address - Fax:
Practice Address - Street 1:305 KNOBCONE DR UNIT 202
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-5711
Practice Address - Country:US
Practice Address - Phone:310-954-7492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12716103TC0700X, 103T00000X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY127160Medicaid
CA74310OtherMANAGED HEALTH NETWORK
CAPSY127160Medicaid