Provider Demographics
NPI:1134372097
Name:PETTERSON POGEMILLER, STEPHANIE (PT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PETTERSON POGEMILLER
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 1:521 5TH AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10175-0003
Mailing Address - Country:US
Mailing Address - Phone:212-692-9558
Mailing Address - Fax:212-692-9296
Practice Address - Street 1:521 5TH AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10175-0003
Practice Address - Country:US
Practice Address - Phone:212-692-9558
Practice Address - Fax:212-692-9296
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030589-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist