Provider Demographics
NPI:1073153300
Name:FAWCETT, STEPHANIE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:FAWCETT
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 1:2310 PHEASANT PL
Mailing Address - Street 2:
Mailing Address - City:EUDORA
Mailing Address - State:KS
Mailing Address - Zip Code:66025-8153
Mailing Address - Country:US
Mailing Address - Phone:913-486-6404
Mailing Address - Fax:
Practice Address - Street 1:1010 EAST ST
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-9557
Practice Address - Country:US
Practice Address - Phone:913-369-8705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist