Provider Demographics
NPI:1104480078
Name:LOCKINGEN, STEPHANIE (PT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LOCKINGEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 COMSTOCK CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6798
Mailing Address - Country:US
Mailing Address - Phone:817-602-0639
Mailing Address - Fax:
Practice Address - Street 1:5171 S COTTONWOOD ST STE 630
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5704
Practice Address - Country:US
Practice Address - Phone:801-507-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11225890-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11225890-2401OtherPHYSICAL THERAPY LICENSE