Provider Demographics
NPI:1770859357
Name:CLINES, STEPHANIE H (PHD, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:H
Last Name:CLINES
Suffix:
Gender:F
Credentials:PHD, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1090
Mailing Address - Country:US
Mailing Address - Phone:203-365-4475
Mailing Address - Fax:
Practice Address - Street 1:5151 PARK AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1090
Practice Address - Country:US
Practice Address - Phone:203-365-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110168972255A2300X
VA01260024932255A2300X
CT0008152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer