Provider Demographics
NPI:1104181650
Name:DEPAUL, STEFANIE (PT, DPT, CSCS, RYT)
Entity type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:
Last Name:DEPAUL
Suffix:
Gender:F
Credentials:PT, DPT, CSCS, RYT
Other - Prefix:DR
Other - First Name:STEFANIE
Other - Middle Name:
Other - Last Name:ROUSSELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, CSCS, RYT
Mailing Address - Street 1:62 MONTVALE AVE STE Z
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3600
Mailing Address - Country:US
Mailing Address - Phone:617-843-5320
Mailing Address - Fax:774-272-8474
Practice Address - Street 1:62 MONTVALE AVE STE Z
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3600
Practice Address - Country:US
Practice Address - Phone:617-843-5320
Practice Address - Fax:774-272-8474
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty