Provider Demographics
NPI:1053341461
Name:STEVENS, NORMAN RAY (LISAC)
Entity type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:RAY
Last Name:STEVENS
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4466
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040
Mailing Address - Country:US
Mailing Address - Phone:928-645-6840
Mailing Address - Fax:928-645-8158
Practice Address - Street 1:337 N. NAVAJO DRIVE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-6840
Practice Address - Fax:928-645-8158
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11673101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ972605Medicaid