Provider Demographics
NPI:1184048688
Name:HJORTEDAL, STEPHANIE RENEE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:HJORTEDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8750 TALLON LANE NE.
Mailing Address - Street 2:HAWKS PRAIRIE PHYSICAL THERAPY
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516
Mailing Address - Country:US
Mailing Address - Phone:360-456-1072
Mailing Address - Fax:360-459-9954
Practice Address - Street 1:8750 TALLON LANE NE.
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516
Practice Address - Country:US
Practice Address - Phone:360-456-1072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1603410612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer