Provider Demographics
NPI:1407686165
Name:DIVITA, STEPHANIE MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:DIVITA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 ANZA WAY
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-5509
Mailing Address - Country:US
Mailing Address - Phone:559-365-1725
Mailing Address - Fax:
Practice Address - Street 1:13939 E 14TH ST STE 150
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2601
Practice Address - Country:US
Practice Address - Phone:510-343-8328
Practice Address - Fax:510-343-8302
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist