Basic Information
| Provider Information | |||||||||
| NPI: | 1235322769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STRACK | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 2603 W PLEASANT GROVE RD | ||||||||
| Address2: | STE 104 | ||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727585804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796361187 | ||||||||
| FaxNumber: | 4796361197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 01/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 2892 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT9349 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2014038484 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 756620 | 01 | OPTUM | OTHER | MA4370093 | 01 | MO | MEDICARE PTAN | OTHER | USES NPI | 01 | BCBS-ANTHEM | OTHER |