Provider Demographics
NPI:1356643712
Name:DUFFY-GRAHAM, STEPHANIE GAYLE (PTA)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:GAYLE
Last Name:DUFFY-GRAHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 GROVE AVE APT 27G
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1539
Mailing Address - Country:US
Mailing Address - Phone:732-642-5957
Mailing Address - Fax:
Practice Address - Street 1:1030 GROVE AVE
Practice Address - Street 2:APT. 27G
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1590
Practice Address - Country:US
Practice Address - Phone:732-642-5957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00100700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant