Provider Demographics
NPI:1366509929
Name:STEPHENSON, JOHN T (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24520 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6800
Mailing Address - Country:US
Mailing Address - Phone:310-428-6708
Mailing Address - Fax:310-375-5262
Practice Address - Street 1:24520 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6800
Practice Address - Country:US
Practice Address - Phone:310-428-6708
Practice Address - Fax:310-375-5262
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16157103G00000X, 103TC0700X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY161571Medicaid
CAPSY161571Medicaid