=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215123351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH LYNN STEVENSON L.M.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 09/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4610 SAWMILL RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43220-2247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-538-0983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6085 LONDON GROVEPORT RD
-----------------------------------------------------
City | GROVE CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43123-8947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-286-6795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 33.015954
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------