Provider Demographics
NPI:1003011651
Name:STEDELIN, MARY L (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:STEDELIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NELMS AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-4930
Mailing Address - Country:US
Mailing Address - Phone:618-553-5097
Mailing Address - Fax:
Practice Address - Street 1:208 ZACHERY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6712
Practice Address - Country:US
Practice Address - Phone:618-204-5497
Practice Address - Fax:618-204-5487
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist