Basic Information
| Provider Information | |||||||||
| NPI: | 1255875084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69030 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212649030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 MANHATTAN SQ | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236666262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578253400 | ||||||||
| FaxNumber: | 7578250392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2016 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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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 | 25323 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305210800 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Q55787A | 01 | VA | INDIVIDUAL MEDICARE PTAN | OTHER | C05954 | 01 | VA | GROUP MEDICARE PTAN | OTHER | 1255875084 | 05 | VA | MEDICAID |