Healthcare Provider Details

I. General information

NPI: 1942489794
Provider Name (Legal Business Name): STEPHANIE LIDDLE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 VALENCIA DR
IDAHO FALLS ID
83404-7575
US

IV. Provider business mailing address

1940 S BONITO WAY STE 190
MERIDIAN ID
83642-5618
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-3332
  • Fax: 208-529-3336
Mailing address:
  • Phone: 208-287-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-954
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-077
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: