Provider Demographics
NPI:1063633964
Name:RUDISILL, STEPHANIE MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:RUDISILL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 NORTHILL DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5018
Mailing Address - Country:US
Mailing Address - Phone:972-238-7192
Mailing Address - Fax:972-238-7192
Practice Address - Street 1:1640 REDSTONE CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7605
Practice Address - Country:US
Practice Address - Phone:214-575-9820
Practice Address - Fax:214-575-9846
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109688225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist