Provider Demographics
NPI:1164613782
Name:FOUTTY, STEPHANIE MARIE (MPT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:FOUTTY
Suffix:
Gender:F
Credentials:MPT, ATC
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:FOUTTY-BONNOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MTP, ATC
Mailing Address - Street 1:1605 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1081
Mailing Address - Country:US
Mailing Address - Phone:304-295-7290
Mailing Address - Fax:304-295-5922
Practice Address - Street 1:1605 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1081
Practice Address - Country:US
Practice Address - Phone:304-295-7290
Practice Address - Fax:304-295-5922
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2022-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT002637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0137817Medicaid
WV3810009961Medicaid
WV516510Medicare UPIN
OH0137817Medicaid