Provider Demographics
NPI:1952512741
Name:OVERHOLT, STEPHANIE ROSE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSE
Last Name:OVERHOLT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 CHISWICK RD APT 4
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5317
Mailing Address - Country:US
Mailing Address - Phone:315-527-2566
Mailing Address - Fax:
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3225
Practice Address - Country:US
Practice Address - Phone:781-979-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17279225100000X
NY026403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist