Provider Demographics
NPI:1407518632
Name:STEPHENS, AMY L (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 TANOAK LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7919
Mailing Address - Country:US
Mailing Address - Phone:630-428-9098
Mailing Address - Fax:
Practice Address - Street 1:215 55TH ST
Practice Address - Street 2:
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-1578
Practice Address - Country:US
Practice Address - Phone:630-468-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007647225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant