Provider Demographics
NPI:1598024432
Name:ALLDREDGE, STEPHANIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ALLDREDGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 N HARBOR BLVD # B
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1310
Mailing Address - Country:US
Mailing Address - Phone:714-870-8478
Mailing Address - Fax:714-870-8405
Practice Address - Street 1:1027 N HARBOR BLVD # B
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1310
Practice Address - Country:US
Practice Address - Phone:714-870-8478
Practice Address - Fax:714-870-8405
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-13
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT386002081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT38600OtherLICENSE