Provider Demographics
NPI:1992091441
Name:STEVENS, MARION T (LPC)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:T
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARION
Other - Middle Name:
Other - Last Name:JIMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1209 CHERRY AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-1205
Mailing Address - Country:US
Mailing Address - Phone:920-664-2490
Mailing Address - Fax:
Practice Address - Street 1:5109 WORLD DAIRY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-3807
Practice Address - Country:US
Practice Address - Phone:608-242-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4090-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42229700Medicaid