Provider Demographics
NPI:1689062580
Name:CARROLL, STEPHANIE A (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:CARROLL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4225
Mailing Address - Country:US
Mailing Address - Phone:386-756-0077
Mailing Address - Fax:386-756-6811
Practice Address - Street 1:733 DUNLAWTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4225
Practice Address - Country:US
Practice Address - Phone:386-756-0077
Practice Address - Fax:386-756-6811
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 29205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist