Provider Demographics
NPI:1679940449
Name:STEPHENS, BRENDAN A (MED, LPC)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:A
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 MILLEDGE CIR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-4336
Mailing Address - Country:US
Mailing Address - Phone:706-540-3566
Mailing Address - Fax:
Practice Address - Street 1:455 N LUMPKIN ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2744
Practice Address - Country:US
Practice Address - Phone:706-540-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008511101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional