Provider Demographics
NPI:1629559877
Name:STEPHAN, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9494 E TS AVE
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-8501
Mailing Address - Country:US
Mailing Address - Phone:269-870-6528
Mailing Address - Fax:
Practice Address - Street 1:9494 E TS AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-8501
Practice Address - Country:US
Practice Address - Phone:269-870-6528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIN354183225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN354183Medicaid