Provider Demographics
NPI:1588962443
Name:VICKERS, STEPHANIE L (PT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 S DAY ST
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-4528
Mailing Address - Country:US
Mailing Address - Phone:979-645-0730
Mailing Address - Fax:
Practice Address - Street 1:2117 S DAY ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-4528
Practice Address - Country:US
Practice Address - Phone:979-830-1002
Practice Address - Fax:979-830-5247
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1110062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist