Provider Demographics
NPI:1275046849
Name:MATOS-O'CONNELL, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MATOS-O'CONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MATOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:20 FLINT MINE RD
Mailing Address - Street 2:
Mailing Address - City:COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12051-2801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 FLINT MINE RD
Practice Address - Street 2:
Practice Address - City:COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12051-2801
Practice Address - Country:US
Practice Address - Phone:518-528-9351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008670224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant