Provider Demographics
NPI:1588040323
Name:ODA, STEPHANIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ODA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2249 LOOKOUT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1815 W. 213TH ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2852
Practice Address - Country:US
Practice Address - Phone:310-328-0275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist