Provider Demographics
NPI:1083107189
Name:STAHL, TERESA (COTA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:STAHL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33405 WESLEY RD
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-7227
Mailing Address - Country:US
Mailing Address - Phone:352-460-2091
Mailing Address - Fax:
Practice Address - Street 1:4501 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-460-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16302224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant