Provider Demographics
NPI:1386166296
Name:CAMPBELL, STEPHANIE (PTA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CAMPBELL
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 1:6864 HUDNALL RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-3524
Mailing Address - Country:US
Mailing Address - Phone:409-466-8995
Mailing Address - Fax:
Practice Address - Street 1:3635 CALDER AVE STE 109
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5044
Practice Address - Country:US
Practice Address - Phone:409-673-7641
Practice Address - Fax:409-833-7235
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2029304225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant