Provider Demographics
NPI:1235322769
Name:DAVIDSON, STEPHANIE LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:STRACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:2603 W PLEASANT GROVE RD
Practice Address - Street 2:STE 104
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-5804
Practice Address - Country:US
Practice Address - Phone:479-636-1187
Practice Address - Fax:479-636-1197
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2892225100000X
GAPT9349225100000X
MO2014038484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
756620OtherOPTUM
MOMA4370093OtherMEDICARE PTAN
USES NPIOtherBCBS-ANTHEM
USES NPIOtherBCBS-ANTHEM