Provider Demographics
NPI:1184021727
Name:MARESKA, STEPHANIE NICHOLE (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICHOLE
Last Name:MARESKA
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 1:1335 E 625 S
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-8663
Mailing Address - Country:US
Mailing Address - Phone:219-252-9172
Mailing Address - Fax:
Practice Address - Street 1:1335 E 625 S
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-8663
Practice Address - Country:US
Practice Address - Phone:219-252-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002754A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant