Provider Demographics
NPI:1902023252
Name:STEPHENSON, KENNETH J (LPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DUTCHMANS MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-3004
Mailing Address - Country:US
Mailing Address - Phone:704-951-0055
Mailing Address - Fax:
Practice Address - Street 1:4389 INDIAN TRAIL FAIRVIEW RD STE 23
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9649
Practice Address - Country:US
Practice Address - Phone:704-526-9905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4811101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11871065OtherCAQH
NC0312590692OtherLIABILITY INSURANCE HPSO
NC6102986Medicaid
NC9727178OtherAETNA