Basic Information
| Provider Information | |||||||||
| NPI: | 1225480569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIED | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEYDEN | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6169 S JOG RD | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334676579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Practice Location | |||||||||
| Address1: | 6169 S JOG RD | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334676579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-05489 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2016033281 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT33059 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.