Provider Demographics
NPI:1598998080
Name:STEPHENSON, ELIZABETH ANN (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:STEPHENSON
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 1:400 E HILLCREST DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2470
Mailing Address - Country:US
Mailing Address - Phone:815-758-5508
Mailing Address - Fax:815-758-5537
Practice Address - Street 1:400 E HILLCREST DR STE 110
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2470
Practice Address - Country:US
Practice Address - Phone:815-758-5508
Practice Address - Fax:815-758-5537
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6240740001OtherMEDICARE PTAN