Provider Demographics
NPI:1073606786
Name:STEFANICK, DIANNE MARIE (MA,ATR,LPAT,B-C)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:MARIE
Last Name:STEFANICK
Suffix:
Gender:F
Credentials:MA,ATR,LPAT,B-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 STARLING SQUARE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056
Mailing Address - Country:US
Mailing Address - Phone:601-924-1987
Mailing Address - Fax:
Practice Address - Street 1:5 STARLING SQUARE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-924-1987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPAT0002221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist