Provider Demographics
NPI:1831222363
Name:STEPHENSON, MARY ELLEN (BSPT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3338 KNOW IT ALL LN
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-7599
Mailing Address - Country:US
Mailing Address - Phone:417-860-6319
Mailing Address - Fax:
Practice Address - Street 1:502 W 5TH ST
Practice Address - Street 2:MSSD SKYVIEW SCHOOL #30
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1435
Practice Address - Country:US
Practice Address - Phone:417-926-4880
Practice Address - Fax:417-926-5044
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00476225100000X, 2251G0304X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1366582827Medicaid