Provider Demographics
NPI:1659327880
Name:PORTER, STEPHANIE S (LPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
Last Name:PORTER
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4004
Mailing Address - Country:US
Mailing Address - Phone:330-758-9400
Mailing Address - Fax:330-726-8676
Practice Address - Street 1:1265 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4004
Practice Address - Country:US
Practice Address - Phone:330-758-9400
Practice Address - Fax:330-726-8676
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT008791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2450904Medicaid
OHST4119571Medicare PIN