Provider Demographics
NPI:1780939009
Name:BAZAL, STEPHANIE PATRICIA (DPT, GCS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:PATRICIA
Last Name:BAZAL
Suffix:
Gender:F
Credentials:DPT, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 PINE CONE LN
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-8803
Mailing Address - Country:US
Mailing Address - Phone:715-222-8826
Mailing Address - Fax:
Practice Address - Street 1:475 CHIPPEWA MALL DR
Practice Address - Street 2:418
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5034
Practice Address - Country:US
Practice Address - Phone:715-720-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8982225100000X
WI13250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist