Provider Demographics
NPI:1962579292
Name:REID, STEFANIE ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:ELIZABETH
Last Name:REID
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:ELIZABETH
Other - Last Name:LAMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:4740 CHERRY HILL RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1330
Practice Address - Country:US
Practice Address - Phone:240-965-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5735024225100000X
WI5735-0242251P0200X
MD27705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40307000Medicaid