Basic Information
Provider Information | |||||||||
NPI: | 1669404117 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STETZER | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 659 S SALISBURY BLVD STE 1B | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218015458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105487600 | ||||||||
FaxNumber: | 4105482651 | ||||||||
Practice Location | |||||||||
Address1: | 106 MILFORD ST STE 601 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218046938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105487600 | ||||||||
FaxNumber: | 4105482651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 04/10/2014 | ||||||||
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 | 20376 | MD | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 810582810 | 01 | MD | MAMSI | OTHER | 402630600 | 05 | MD |   | MEDICAID | 61138805 | 01 | MD | CAREFIRST BCBS MD | OTHER | 810582810 | 01 | MD | OPT CHOICE | OTHER | G5400002 | 01 | MD | BLUECHOICE FEDERAL BCBS | OTHER | 810582810 | 01 | MD | AETNA | OTHER | 810582810 | 01 | MD | MDIPA | OTHER |