Provider Demographics
NPI:1942489794
Name:LIDDLE, STEPHANIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LIDDLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:3125 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7575
Practice Address - Country:US
Practice Address - Phone:208-529-3332
Practice Address - Fax:208-529-3336
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-0772255A2300X
IDPT-954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer