Provider Demographics
NPI: | 1932293024 |
---|---|
Name: | STEPHENSON, BRYAN TODD (MSPT) |
Entity Type: | Individual |
Prefix: | |
First Name: | BRYAN |
Middle Name: | TODD |
Last Name: | STEPHENSON |
Suffix: | |
Gender: | M |
Credentials: | MSPT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 10525 HOLLINGSWORTH WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92127 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 858-693-7993 |
Mailing Address - Fax: | 619-445-5368 |
Practice Address - Street 1: | 1620 ALPINE BLVD |
Practice Address - Street 2: | SUITE 211 |
Practice Address - City: | ALPINE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91901-1102 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-445-3168 |
Practice Address - Fax: | 619-445-5368 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-03 |
Last Update Date: | 2008-10-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | PT26642 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 0PT266420 | Other | BLUE SHIELD COMMERCIAL |
CA | 0PT266420 | Other | BLUE SHIELD GOVERNMENT |
CA | PT0266420 | Medicaid | |
CA | PT0266420 | Medicaid |