Provider Demographics
NPI:1467875955
Name:O'BRIEN, STEPHANIE LYNNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNNE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNNE
Other - Last Name:DOMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:573 STATION RD
Mailing Address - Street 2:APT 12
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-2284
Mailing Address - Country:US
Mailing Address - Phone:937-479-7336
Mailing Address - Fax:
Practice Address - Street 1:5500 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1476
Practice Address - Country:US
Practice Address - Phone:614-575-9003
Practice Address - Fax:614-575-9101
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.05637224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant