Provider Demographics
NPI:1912348475
Name:STEPHENS, NATHANAEL MARK (LP, LPC)
Entity type:Individual
Prefix:DR
First Name:NATHANAEL
Middle Name:MARK
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:LP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 EATON RAPIDS RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-6307
Mailing Address - Country:US
Mailing Address - Phone:517-342-4253
Mailing Address - Fax:517-882-9969
Practice Address - Street 1:650 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:DIMONDALE
Practice Address - State:MI
Practice Address - Zip Code:48821-9642
Practice Address - Country:US
Practice Address - Phone:517-507-6410
Practice Address - Fax:517-882-9969
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010248101Y00000X
MI6401010246103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912348475Medicaid