Provider Demographics
NPI:1508971169
Name:EDWARDS, STEPHEN BLAINE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BLAINE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 RALSTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7844
Mailing Address - Country:US
Mailing Address - Phone:805-804-4168
Mailing Address - Fax:805-830-1177
Practice Address - Street 1:3525 LOMA VISTA RD STE C
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3165
Practice Address - Country:US
Practice Address - Phone:805-652-6955
Practice Address - Fax:805-652-6959
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 226012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22601OtherSTATE LICENSE
CAWPT22601CMedicare PIN
CAW268Medicare PIN
CAW268BMedicare PIN
CA0878110001Medicare NSC
CAWPT22601AMedicare PIN