Provider Demographics
NPI:1245479963
Name:BLACK, STEPHANIE (MPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 CALLOWAY DR STE 603
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-2514
Mailing Address - Country:US
Mailing Address - Phone:661-377-1700
Mailing Address - Fax:
Practice Address - Street 1:2838 OSWELL ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-2704
Practice Address - Country:US
Practice Address - Phone:661-377-1700
Practice Address - Fax:661-616-9199
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34860225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABN316ZMedicare PIN