Provider Demographics
NPI:1457441149
Name:MCKETA, STEPHANIE LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:MCKETA
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 1:1265 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3501
Mailing Address - Country:US
Mailing Address - Phone:724-465-2676
Mailing Address - Fax:724-465-0193
Practice Address - Street 1:1265 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3501
Practice Address - Country:US
Practice Address - Phone:724-465-2676
Practice Address - Fax:724-465-0193
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7636368OtherAETNA
PA189730OtherHEALTH AMER/HEALTH ASSUR.
PAMC1387126OtherHIGHMARK BLUE SHIELD
PA396749Medicare ID - Type UnspecifiedMEDICARE