Provider Demographics
NPI:1477008233
Name:FITZSIMMONS, STEPHANIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FITZSIMMONS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:GOGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3815 E MAIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2488
Mailing Address - Country:US
Mailing Address - Phone:630-584-7530
Mailing Address - Fax:630-584-7762
Practice Address - Street 1:3815 E MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2488
Practice Address - Country:US
Practice Address - Phone:630-584-7530
Practice Address - Fax:630-584-7762
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist