Provider Demographics
NPI:1205855962
Name:STEPHENS, ANDREW B (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:B
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:EASTSOUND
Mailing Address - State:WA
Mailing Address - Zip Code:98245
Mailing Address - Country:US
Mailing Address - Phone:360-376-6604
Mailing Address - Fax:360-376-4059
Practice Address - Street 1:49 DEYE LANE
Practice Address - Street 2:
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245
Practice Address - Country:US
Practice Address - Phone:360-376-6604
Practice Address - Fax:360-376-4059
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00007789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7123748Medicaid
WA7123748Medicaid