Provider Demographics
NPI:1538562608
Name:GEORGE, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GEORGE
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 1:6020 CONSTITUTION AVE NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5900
Mailing Address - Country:US
Mailing Address - Phone:505-255-5099
Mailing Address - Fax:505-255-4206
Practice Address - Street 1:6020 CONSTITUTION AVE NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5900
Practice Address - Country:US
Practice Address - Phone:505-255-5099
Practice Address - Fax:505-255-4206
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0927225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant