Provider Demographics
NPI:1023850112
Name:CANTWELL, STEFAN (DPT)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:CANTWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5349 ADAMS AVE PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4736
Mailing Address - Country:US
Mailing Address - Phone:801-479-9865
Mailing Address - Fax:
Practice Address - Street 1:5360 S 1900 W STE B3
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2980
Practice Address - Country:US
Practice Address - Phone:801-774-8600
Practice Address - Fax:801-774-8681
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13970066-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist