Provider Demographics
NPI:1265498216
Name:STODDEN, MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:STODDEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 N 205TH ST
Mailing Address - Street 2:140
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4740
Mailing Address - Country:US
Mailing Address - Phone:402-289-5013
Mailing Address - Fax:402-289-5018
Practice Address - Street 1:1405 N 205 STREET
Practice Address - Street 2:140
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022
Practice Address - Country:US
Practice Address - Phone:402-289-5013
Practice Address - Fax:402-289-5018
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02755225100000X
NE1604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE39960OtherBCBS
NE41213595668022A002OtherTRIWEST
NE10025112300Medicaid
216813OtherCOVENTRY
NE10025112300Medicaid