Provider Demographics
NPI:1215306717
Name:STEVENSON, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 OAK STREET
Mailing Address - Street 2:
Mailing Address - City:CHEBANSE
Mailing Address - State:IL
Mailing Address - Zip Code:60922
Mailing Address - Country:US
Mailing Address - Phone:815-383-6775
Mailing Address - Fax:
Practice Address - Street 1:314 OAK STREET
Practice Address - Street 2:
Practice Address - City:CHEBANSE
Practice Address - State:IL
Practice Address - Zip Code:60922
Practice Address - Country:US
Practice Address - Phone:815-383-6775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19769173F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173F00000XOther Service ProvidersSleep Specialist, PhD