Provider Demographics
NPI:1356569164
Name:STEVENSON, EDWARD ELSWORTH JR (PH D)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ELSWORTH
Last Name:STEVENSON
Suffix:JR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1151
Mailing Address - Country:US
Mailing Address - Phone:516-868-2583
Mailing Address - Fax:516-868-6253
Practice Address - Street 1:137 PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1151
Practice Address - Country:US
Practice Address - Phone:516-868-2583
Practice Address - Fax:516-868-6253
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005156-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical