Healthcare Provider Details

I. General information

NPI: 1649376690
Provider Name (Legal Business Name): STEPHANIE M BRIDWELL MSPT, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11375 BIG BEND RD
RIVERVIEW FL
33579-7183
US

IV. Provider business mailing address

3903 NORTHDALE BLVD STE 111W
TAMPA FL
33624-1853
US

V. Phone/Fax

Practice location:
  • Phone: 813-805-8167
  • Fax:
Mailing address:
  • Phone: 813-381-6778
  • Fax: 440-815-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT22346
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT22346
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22346
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: