Provider Demographics
NPI:1912489139
Name:WEN, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WEN
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 1:2450 WALTERS WAY APT 16
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3668
Mailing Address - Country:US
Mailing Address - Phone:925-448-5327
Mailing Address - Fax:
Practice Address - Street 1:540 RALSTON AVE STE B
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2866
Practice Address - Country:US
Practice Address - Phone:650-363-5668
Practice Address - Fax:650-363-5669
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA49445225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant