Provider Demographics
NPI:1144206533
Name:ADDISON, STEPHANIE L (PT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:ADDISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:RAUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 667744
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28266
Mailing Address - Country:US
Mailing Address - Phone:704-588-4757
Mailing Address - Fax:704-583-5367
Practice Address - Street 1:4221 TUCKASEEGEE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208
Practice Address - Country:US
Practice Address - Phone:704-392-4057
Practice Address - Fax:704-392-4788
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1256WOtherBCBS
NC5460678OtherAETNA