Provider Demographics
NPI:1457675910
Name:MARTIN, STEPHANIE (MSOT, OTR)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2427
Mailing Address - Country:US
Mailing Address - Phone:617-308-6461
Mailing Address - Fax:617-308-6461
Practice Address - Street 1:1430 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2427
Practice Address - Country:US
Practice Address - Phone:617-308-6461
Practice Address - Fax:617-308-6461
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008874225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist