Provider Demographics
NPI:1548482672
Name:LEARY, STEPHEN MICHEAL (PT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHEAL
Last Name:LEARY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19570 BALL BUTTE CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9148
Mailing Address - Country:US
Mailing Address - Phone:541-312-2252
Mailing Address - Fax:
Practice Address - Street 1:147 SW SHEVLIN HIXON DR
Practice Address - Street 2:SUITE 104
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3130
Practice Address - Country:US
Practice Address - Phone:541-312-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR48852251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ6507-02OtherPACIFIC SOURCE PIN
OR840573000OtherBLUE CROSS PIN
ORJ6507-02OtherPACIFIC SOURCE PIN