Provider Demographics
NPI:1679805477
Name:STEVENS, TARA MARIE (MED, LADC UNDER SU)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MED, LADC UNDER SU
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4047
Mailing Address - Country:US
Mailing Address - Phone:918-465-3381
Mailing Address - Fax:918-465-3053
Practice Address - Street 1:309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4047
Practice Address - Country:US
Practice Address - Phone:918-465-3381
Practice Address - Fax:918-465-3053
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)