Provider Demographics
NPI:1093204976
Name:STEFANOVICH, ELENA (OTR)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:STEFANOVICH
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 1:578 MAYFAIR DR S FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 MERMAID AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2005
Practice Address - Country:US
Practice Address - Phone:718-333-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-06
Last Update Date:2018-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022546225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist