Provider Demographics
NPI:1629181748
Name:WHITE, STEPHEN C (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MEDICAL ARTS AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2708
Mailing Address - Country:US
Mailing Address - Phone:505-272-9020
Mailing Address - Fax:505-232-9606
Practice Address - Street 1:1025 MEDICAL ARTS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2708
Practice Address - Country:US
Practice Address - Phone:505-272-9020
Practice Address - Fax:505-232-9606
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7649225100000X
NM4366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
102255331OtherOWCP FACILITY ID