Provider Demographics
NPI:1487130456
Name:MORELAND, STEPHANIE CRYSTEN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CRYSTEN
Last Name:MORELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 DAPHNE DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-3200
Mailing Address - Country:US
Mailing Address - Phone:423-702-0475
Mailing Address - Fax:
Practice Address - Street 1:13030 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-8374
Practice Address - Country:US
Practice Address - Phone:757-249-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604395225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant