Provider Demographics
NPI:1356814768
Name:GONZALEZ, STEPHANIE C (OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 S 15TH ST APT 2004
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-5019
Mailing Address - Country:US
Mailing Address - Phone:832-860-3591
Mailing Address - Fax:
Practice Address - Street 1:822 MONTGOMERY AVE STE 306
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1948
Practice Address - Country:US
Practice Address - Phone:832-860-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC016005225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics