Provider Demographics
NPI:1750746723
Name:KING, STEPHANIE (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 PARKER DR
Mailing Address - Street 2:APT 6
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4237
Mailing Address - Country:US
Mailing Address - Phone:559-827-6722
Mailing Address - Fax:
Practice Address - Street 1:2295 S VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7925
Practice Address - Country:US
Practice Address - Phone:909-427-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 21111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist