Provider Demographics
NPI:1376126052
Name:ATKINS, STEPHANIE SIMONE (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SIMONE
Last Name:ATKINS
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:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-0575
Mailing Address - Country:US
Mailing Address - Phone:903-283-4329
Mailing Address - Fax:
Practice Address - Street 1:5151 STATE HIGHWAY 110
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-3887
Practice Address - Country:US
Practice Address - Phone:903-283-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215802224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant