Provider Demographics
NPI:1104181650
Name:DEPAUL, STEFANIE ROUSSELLE (PT, DPT, CSCS, RYT)
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:ROUSSELLE
Last Name:DEPAUL
Suffix:
Gender:F
Credentials:PT, DPT, CSCS, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 AVERY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1005
Mailing Address - Country:US
Mailing Address - Phone:617-375-8644
Mailing Address - Fax:617-375-8581
Practice Address - Street 1:62 MONTVALE AVE STE Z
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3600
Practice Address - Country:US
Practice Address - Phone:617-375-8644
Practice Address - Fax:617-375-8581
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist