Provider Demographics
NPI:1154703064
Name:IVY, STEPHENIE (PTA)
Entity type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3782 HIGHWAY 95
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8124
Mailing Address - Country:US
Mailing Address - Phone:928-763-0807
Mailing Address - Fax:
Practice Address - Street 1:3782 HIGHWAY 95
Practice Address - Street 2:SUITE 2
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8124
Practice Address - Country:US
Practice Address - Phone:928-763-0807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11403A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant