Provider Demographics
NPI:1770066193
Name:FOGELSON, STEPHANIE SARAH (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:SARAH
Last Name:FOGELSON
Suffix:
Gender:F
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 1:3475 LA SOMBRA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1511
Mailing Address - Country:US
Mailing Address - Phone:818-631-6860
Mailing Address - Fax:
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4743
Practice Address - Country:US
Practice Address - Phone:818-631-6860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist