Provider Demographics
NPI:1003302688
Name:STEVENS, MARK ANDREW (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:1812 N LAKEWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2635
Practice Address - Country:US
Practice Address - Phone:208-966-4475
Practice Address - Fax:208-966-4475
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013618225100000X
IDPT8200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist