Provider Demographics
NPI:1861401408
Name:MAZMANIAN, STEPHEN MICHAEL (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:MAZMANIAN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 STEINHART AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2747
Mailing Address - Country:US
Mailing Address - Phone:310-318-1938
Mailing Address - Fax:
Practice Address - Street 1:500 N NASH ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2817
Practice Address - Country:US
Practice Address - Phone:310-640-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8073225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic