Provider Demographics
NPI:1285081307
Name:FORTSON, STEPHEN (EDD PCC-S)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:FORTSON
Suffix:
Gender:M
Credentials:EDD PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 IRONGATE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4616
Mailing Address - Country:US
Mailing Address - Phone:937-439-4220
Mailing Address - Fax:
Practice Address - Street 1:51 IRONGATE PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4616
Practice Address - Country:US
Practice Address - Phone:937-439-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-1935101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional