Provider Demographics
NPI:1619228004
Name:STEPHENSON, AMANDA L (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:135 N WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3528
Mailing Address - Country:US
Mailing Address - Phone:309-661-8823
Mailing Address - Fax:309-661-8801
Practice Address - Street 1:865 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-1264
Practice Address - Country:US
Practice Address - Phone:309-649-1572
Practice Address - Fax:309-649-1581
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-019514225100000X
MO2012023605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist