Provider Demographics
NPI:1326392085
Name:MEDIATE, STEPHANIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MEDIATE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ISLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-5620
Mailing Address - Country:US
Mailing Address - Phone:401-369-3496
Mailing Address - Fax:
Practice Address - Street 1:1184 E MAIN RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-2333
Practice Address - Country:US
Practice Address - Phone:401-682-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10293225100000X
RI01627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist