Provider Demographics
NPI:1700133550
Name:BODINE, STEPHEN ROSS (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROSS
Last Name:BODINE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2356
Mailing Address - Country:US
Mailing Address - Phone:303-444-8707
Mailing Address - Fax:303-444-8109
Practice Address - Street 1:3488 GONI RD STE 141
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-7970
Practice Address - Country:US
Practice Address - Phone:775-887-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-11
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist