Provider Demographics
NPI:1932653870
Name:STEPHENSON, ELIZABETH CLARK (LCPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CLARK
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:342 W 1ST S APT 101
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5133
Mailing Address - Country:US
Mailing Address - Phone:208-671-1537
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY # 2201
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5293
Practice Address - Country:US
Practice Address - Phone:208-649-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-7104101YM0800X
IDLPC-6179101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional