Basic Information
| Provider Information | |||||||||
| NPI: | 1447503339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORL | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KALIVODA | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2600 STANWELL DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945204862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256865400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6759 SIERRA CT STE A | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DUBLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945682657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258030530 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2012 | ||||||||
| LastUpdateDate: | 11/28/2016 | ||||||||
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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 | 39506 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.