Provider Demographics
NPI:1619059169
Name:DE SAM LAZARO, STEPHANIE LYNN (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:DE SAM LAZARO
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:BETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:1925 MONTREAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116
Mailing Address - Country:US
Mailing Address - Phone:651-699-5296
Mailing Address - Fax:
Practice Address - Street 1:900 W 94TH STREET
Practice Address - Street 2:THE THERAPY PLACE
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:952-885-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103343225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist