Provider Demographics
NPI:1235385030
Name:STEPHENS, MICHAEL DUANE (ATC, PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DUANE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 TREASURE PALM DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7715
Mailing Address - Country:US
Mailing Address - Phone:850-235-6360
Mailing Address - Fax:850-235-8871
Practice Address - Street 1:120 BECKRICH RD
Practice Address - Street 2:SUITE 130
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2521
Practice Address - Country:US
Practice Address - Phone:850-235-6360
Practice Address - Fax:850-235-7781
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL13082255A2300X
FLPTA20905225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer