Provider Demographics
NPI:1881340974
Name:GUIVENCAN, STEPHANIE KEITH TAGO (PT, DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE KEITH
Middle Name:TAGO
Last Name:GUIVENCAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 SAUNDERS ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1026
Mailing Address - Country:US
Mailing Address - Phone:929-235-4336
Mailing Address - Fax:
Practice Address - Street 1:10825 63RD AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1342
Practice Address - Country:US
Practice Address - Phone:718-896-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-27
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044779-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist