Provider Demographics
NPI:1467116509
Name:WASON, STEPHANIE MICHELLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:WASON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11952 9TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-2308
Mailing Address - Country:US
Mailing Address - Phone:562-519-3999
Mailing Address - Fax:
Practice Address - Street 1:2501 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3132
Practice Address - Country:US
Practice Address - Phone:714-888-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA5098224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant