Healthcare Provider Details

I. General information

NPI: 1831222363
Provider Name (Legal Business Name): MARY ELLEN STEPHENSON BSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W 5TH ST MSSD SKYVIEW SCHOOL #30
MOUNTAIN GROVE MO
65711-1435
US

IV. Provider business mailing address

3338 KNOW IT ALL LN
ROGERSVILLE MO
65742-7599
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-4880
  • Fax: 417-926-5044
Mailing address:
  • Phone: 417-860-6319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00476
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number00476
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number00476
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: