Healthcare Provider Details

I. General information

NPI: 1053307116
Provider Name (Legal Business Name): SUSAN MARIE STEVENS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W 6TH ST
CEDAR FALLS IA
50613-2859
US

IV. Provider business mailing address

PO BOX 1107
CEDAR FALLS IA
50613-0049
US

V. Phone/Fax

Practice location:
  • Phone: 319-277-3166
  • Fax: 319-266-4846
Mailing address:
  • Phone: 319-277-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number000115
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: