Provider Demographics
NPI:1720371230
Name:ANDERSON, STEFANIE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MISS
Other - First Name:STEFANIE
Other - Middle Name:
Other - Last Name:ROUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3148A WEST CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2920
Mailing Address - Country:US
Mailing Address - Phone:419-531-2690
Mailing Address - Fax:
Practice Address - Street 1:412 DRIVE IN LN
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3160
Practice Address - Country:US
Practice Address - Phone:843-761-6732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH433340Medicare PIN
OHH428950Medicare PIN