Provider Demographics
NPI:1508049065
Name:CONCANNON, STEPHANIE LYN (MED)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LYN
Last Name:CONCANNON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:LYN
Other - Last Name:REGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:255 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-3023
Practice Address - Country:US
Practice Address - Phone:781-449-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist