Provider Demographics
NPI:1205045812
Name:STEPHENS, MARY LEE (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:STEPHENS
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 1:11933 E 126TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-5230
Mailing Address - Country:US
Mailing Address - Phone:918-369-3008
Mailing Address - Fax:
Practice Address - Street 1:205 E B ST
Practice Address - Street 2:JENKS PUBLIC SCHOOLS
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3906
Practice Address - Country:US
Practice Address - Phone:918-299-4415
Practice Address - Fax:918-298-6647
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT6502251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics