Provider Demographics
NPI:1528432853
Name:SHANE, STEPHANIE (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SHANE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 MIDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-4223
Mailing Address - Country:US
Mailing Address - Phone:646-483-5763
Mailing Address - Fax:347-287-6873
Practice Address - Street 1:12 W 21ST ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6917
Practice Address - Country:US
Practice Address - Phone:646-484-5763
Practice Address - Fax:347-287-6873
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist