Basic Information
| Provider Information | |||||||||
| NPI: | 1649251091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | MEKEIA | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRIS | ||||||||
| OtherFirstName: | MEKEIA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6320A W UNION HILLS DR | ||||||||
| Address2: | STE 265 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233742424 | ||||||||
| FaxNumber: | 6233742619 | ||||||||
| Practice Location | |||||||||
| Address1: | 6320A W UNION HILLS DR | ||||||||
| Address2: | STE 265 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233742424 | ||||||||
| FaxNumber: | 6233742619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9619 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9447 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7211729 | 05 | NC | MEDICAID | 079RX | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | P00319082 | 01 | NC | MEDICARE RAILROAD | OTHER | E2225 | 01 | NC | MEDCOST | OTHER | Z155550 | 01 | AZ | MEDICARE PTAN | OTHER |