Provider Demographics
NPI:1346648276
Name:MASTROSTEFANO, ANN (COTA)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:MASTROSTEFANO
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 1:5219 88TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-7468
Mailing Address - Country:US
Mailing Address - Phone:262-653-0850
Mailing Address - Fax:
Practice Address - Street 1:5219 88TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-7468
Practice Address - Country:US
Practice Address - Phone:262-653-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5098-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant