Provider Demographics
NPI:1407440902
Name:AUDISH, STEPHANIE MIRAY (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MIRAY
Last Name:AUDISH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19026 KILLOCH WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1028
Mailing Address - Country:US
Mailing Address - Phone:818-642-6170
Mailing Address - Fax:
Practice Address - Street 1:390 N PACIFIC COAST HWY STE 1000
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4401
Practice Address - Country:US
Practice Address - Phone:310-640-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist