Provider Demographics
NPI:1477960870
Name:STEPHENS, MARK (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77516-0724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 7TH ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-4840
Practice Address - Country:US
Practice Address - Phone:979-245-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT55992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer