Provider Demographics
NPI:1649376690
Name:BRIDWELL, STEPHANIE M (MSPT, CSCS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:BRIDWELL
Suffix:
Gender:F
Credentials:MSPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 NORTHDALE BLVD
Mailing Address - Street 2:STE 111W
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1853
Mailing Address - Country:US
Mailing Address - Phone:813-381-6778
Mailing Address - Fax:440-815-2120
Practice Address - Street 1:11375 BIG BEND RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-7183
Practice Address - Country:US
Practice Address - Phone:813-805-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT223462251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEV755ZMedicare UPIN