Provider Demographics
NPI:1649595737
Name:SUDDERTH, STEPHANIE (MPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SUDDERTH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 WILLOW CREEK DRIVE #107
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76085
Mailing Address - Country:US
Mailing Address - Phone:817-550-5058
Mailing Address - Fax:817-550-8177
Practice Address - Street 1:150 WILLOW CREEK DRIVE #107
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76085
Practice Address - Country:US
Practice Address - Phone:817-550-5058
Practice Address - Fax:817-550-8177
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1138725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist