Provider Demographics
NPI:1073861126
Name:WILKS, STEPHANIE ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:WILKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8080 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-924-2424
Mailing Address - Fax:225-408-7984
Practice Address - Street 1:8080 BLUEBONNET BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7827
Practice Address - Country:US
Practice Address - Phone:225-924-2424
Practice Address - Fax:225-408-7984
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07928OtherLA PT LICENSE