Provider Demographics
NPI:1710420104
Name:VAN IDERSTINE, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:VAN IDERSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:POOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-2765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-2765
Practice Address - Country:US
Practice Address - Phone:413-525-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9202225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant