Provider Demographics
NPI:1255578092
Name:STEPHENSON, MARTHA H (LCDCIII)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:H
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:MS
Other - First Name:MARTY
Other - Middle Name:H
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4483 US NORTH 42
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1934
Mailing Address - Country:US
Mailing Address - Phone:513-536-0071
Mailing Address - Fax:513-204-3476
Practice Address - Street 1:4483 US NORTH 42
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040
Practice Address - Country:US
Practice Address - Phone:513-536-0071
Practice Address - Fax:513-204-3476
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00141101YA0400X
OH001411101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0277784Medicaid