Provider Demographics
NPI:1881834844
Name:WOLF, STEPHANIE RENEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RENEE
Last Name:WOLF
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 1:2368 CRATER LAKE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5006
Mailing Address - Country:US
Mailing Address - Phone:541-773-2999
Mailing Address - Fax:541-773-1874
Practice Address - Street 1:2368 CRATER LAKE AVE STE 103
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5006
Practice Address - Country:US
Practice Address - Phone:541-773-2999
Practice Address - Fax:541-773-1874
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8464225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant