Provider Demographics
NPI:1558509307
Name:HERTEL, STEPHANIE A (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:HERTEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-5813
Mailing Address - Country:US
Mailing Address - Phone:620-253-2419
Mailing Address - Fax:
Practice Address - Street 1:2200 SUMMERLON CIR STE D
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2905
Practice Address - Country:US
Practice Address - Phone:620-225-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1401763225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant