Provider Demographics
NPI:1528568250
Name:MEDINA, STEPHANIE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 E 53RD ST S
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67216-3341
Mailing Address - Country:US
Mailing Address - Phone:316-990-2763
Mailing Address - Fax:
Practice Address - Street 1:712 N MONROE AVE
Practice Address - Street 2:
Practice Address - City:SEDGWICK
Practice Address - State:KS
Practice Address - Zip Code:67135-9492
Practice Address - Country:US
Practice Address - Phone:316-772-5185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01305224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant