Provider Demographics
NPI:1528263787
Name:STEVENS, ANGEL (CT)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72258
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-2258
Mailing Address - Country:US
Mailing Address - Phone:907-452-7221
Mailing Address - Fax:
Practice Address - Street 1:2550 LAWLOR RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-6458
Practice Address - Country:US
Practice Address - Phone:907-455-4725
Practice Address - Fax:907-455-4730
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCERTIFICATE 3215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDA4437Medicaid