Provider Demographics
NPI:1053849588
Name:PETRY, STEFEN CHARLES (DPT)
Entity type:Individual
Prefix:
First Name:STEFEN
Middle Name:CHARLES
Last Name:PETRY
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 1:906 MEBANE OAKS RD
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-7951
Mailing Address - Country:US
Mailing Address - Phone:919-563-1825
Mailing Address - Fax:919-563-1833
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-2835
Practice Address - Country:US
Practice Address - Phone:336-243-2702
Practice Address - Fax:336-243-4014
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty