Provider Demographics
NPI:1114153087
Name:GERDES, STEPHANIE LEIGH (COTA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:GERDES
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 1:515 N MESA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5914
Mailing Address - Country:US
Mailing Address - Phone:480-223-4900
Mailing Address - Fax:
Practice Address - Street 1:515 N MESA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5914
Practice Address - Country:US
Practice Address - Phone:480-223-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2603172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker