Provider Demographics
NPI:1013166453
Name:WIEGAND, STEPHANIE RUSSELL (MSPT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:RUSSELL
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:CELENE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:2424 N WYATT DR
Mailing Address - Street 2:SUITE #130
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6115
Mailing Address - Country:US
Mailing Address - Phone:520-784-6570
Mailing Address - Fax:520-784-6574
Practice Address - Street 1:2424 N WYATT DR
Practice Address - Street 2:SUITE #130
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6115
Practice Address - Country:US
Practice Address - Phone:520-784-6570
Practice Address - Fax:520-784-6574
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5586225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic