Provider Demographics
NPI:1821850819
Name:DALE, STEPHANIE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W JUNIPER AVE APT 2122
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3931
Mailing Address - Country:US
Mailing Address - Phone:602-775-0999
Mailing Address - Fax:
Practice Address - Street 1:10861 E BASELINE RD STE A105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-7921
Practice Address - Country:US
Practice Address - Phone:602-775-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014362225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant