Provider Demographics
NPI:1609988252
Name:SMITH, STEPHANIE CERIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CERIE
Last Name:SMITH
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 1:17233 N HOLMES BLVD
Mailing Address - Street 2:STE 1650
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2018
Mailing Address - Country:US
Mailing Address - Phone:602-547-0809
Mailing Address - Fax:602-467-8677
Practice Address - Street 1:17233 N HOLMES BLVD
Practice Address - Street 2:STE 1650
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2018
Practice Address - Country:US
Practice Address - Phone:602-547-0809
Practice Address - Fax:602-467-8677
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ626377Medicaid
AZ69477Medicare ID - Type Unspecified