Provider Demographics
NPI:1316946759
Name:BLOUGH, STEPHANIE MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:BLOUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2345 ERRINGER RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2235
Mailing Address - Country:US
Mailing Address - Phone:805-577-6269
Mailing Address - Fax:805-582-0003
Practice Address - Street 1:2345 ERRINGER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2235
Practice Address - Country:US
Practice Address - Phone:805-577-6269
Practice Address - Fax:805-582-0003
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT29076AMedicare ID - Type Unspecified