Provider Demographics
NPI:1316231335
Name:STEPHENS, ROSLYN
Entity Type:Individual
Prefix:
First Name:ROSLYN
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3806 WINCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-8018
Mailing Address - Country:US
Mailing Address - Phone:706-533-4227
Mailing Address - Fax:
Practice Address - Street 1:580 BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3604
Practice Address - Country:US
Practice Address - Phone:706-364-8501
Practice Address - Fax:706-364-8503
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT 007477225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist