Basic Information
| Provider Information | |||||||||
| NPI: | 1861960726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | WILLIAM | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1844 SOMERFORD DR | ||||||||
| Address2: | |||||||||
| City: | GALENA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430218132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149492647 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11050 MOUNT BELVEDERE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157722778 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2018 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.