Provider Demographics
NPI:1902170780
Name:STEPHENS, SUSAN HOWARD (PT MED)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:HOWARD
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PT MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 CENTRO EAST ST
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-1906
Mailing Address - Country:US
Mailing Address - Phone:415-308-4111
Mailing Address - Fax:
Practice Address - Street 1:2153 CENTRO EAST ST
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-1906
Practice Address - Country:US
Practice Address - Phone:415-308-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32183225100000X
VA2305000709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist