Provider Demographics
NPI:1124202494
Name:WEDDERBURN, STEPHNIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHNIE
Middle Name:
Last Name:WEDDERBURN
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 1:368 W PIKE ST
Mailing Address - Street 2:SUITE 204-A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3240
Mailing Address - Country:US
Mailing Address - Phone:770-755-5278
Mailing Address - Fax:770-755-5682
Practice Address - Street 1:368 W PIKE ST
Practice Address - Street 2:SUITE 204-A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3240
Practice Address - Country:US
Practice Address - Phone:770-755-5278
Practice Address - Fax:770-755-5682
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist