Healthcare Provider Details

I. General information

NPI: 1295040897
Provider Name (Legal Business Name): STEPHANIE WOLLA O'CONNELL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GALLBERRY LN
WAXHAW NC
28173-0161
US

IV. Provider business mailing address

2510 HATHERLY RD
CHARLOTTE NC
28209-3455
US

V. Phone/Fax

Practice location:
  • Phone: 704-649-4509
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP17584
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number6262
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: