Provider Demographics
NPI:1124250964
Name:HINE, STEPHANIE R (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:HINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:FREED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:1220A N WAYNE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2345
Practice Address - Country:US
Practice Address - Phone:260-624-2288
Practice Address - Fax:260-624-2286
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009940A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200965550AMedicaid
IN100257920GOtherGROUP MEDICAID
IN156546OtherGROUP MEDICARE