Provider Demographics
NPI:1851882732
Name:IHEGBORO, STEFFAN (DPT)
Entity Type:Individual
Prefix:
First Name:STEFFAN
Middle Name:
Last Name:IHEGBORO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 MARATHON BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3409
Mailing Address - Country:US
Mailing Address - Phone:512-358-1400
Mailing Address - Fax:737-300-2519
Practice Address - Street 1:4201 MARATHON BLVD STE 204
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3409
Practice Address - Country:US
Practice Address - Phone:512-358-1400
Practice Address - Fax:737-300-2519
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3122015225100000X
TX1307901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty