Provider Demographics
NPI:1235671751
Name:STEVENSON HOUCK, MARTHA SHANNON (MPT)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:SHANNON
Last Name:STEVENSON HOUCK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:586 LONE STREE DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8170
Practice Address - Country:US
Practice Address - Phone:843-884-7880
Practice Address - Fax:843-884-6635
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist