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
StateLicense IDTaxonomies
CAPT26642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT266420OtherBLUE SHIELD COMMERCIAL
CA0PT266420OtherBLUE SHIELD GOVERNMENT
CAPT0266420Medicaid
CAPT0266420Medicaid