Provider Demographics
NPI:1366606691
Name:BANDY, STEPHANIE R (DPT, ATC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:BANDY
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 VILLA PARK CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-1540
Mailing Address - Country:US
Mailing Address - Phone:309-825-5259
Mailing Address - Fax:
Practice Address - Street 1:5750 COVENTRY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7166
Practice Address - Country:US
Practice Address - Phone:260-436-9337
Practice Address - Fax:260-436-9626
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009611A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist