Provider Demographics
NPI:1083325344
Name:STEPHAN, MACKENZIE MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MARIE
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-8607
Mailing Address - Country:US
Mailing Address - Phone:972-724-2400
Mailing Address - Fax:972-724-2495
Practice Address - Street 1:4364 HERITAGE TRACE PKWY STE 108
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9125
Practice Address - Country:US
Practice Address - Phone:817-379-1400
Practice Address - Fax:817-379-1404
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPENDING225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist