Provider Demographics
NPI:1366109316
Name:STEPHENS, DAVID RUSSELL
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RUSSELL
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 SHAUFF PL
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37409-2320
Mailing Address - Country:US
Mailing Address - Phone:971-801-5230
Mailing Address - Fax:
Practice Address - Street 1:520 S PIERCE AVE STE 150
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2711
Practice Address - Country:US
Practice Address - Phone:641-494-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC61222177104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker