Provider Demographics
NPI:1295959153
Name:OVERBAUGH, STEPHANIE (MPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:OVERBAUGH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 CENTER AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3039
Mailing Address - Country:US
Mailing Address - Phone:714-901-4200
Mailing Address - Fax:
Practice Address - Street 1:23131 LAKE CENTER DR STE D
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6813
Practice Address - Country:US
Practice Address - Phone:949-595-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT24951AMedicare UPIN