Provider Demographics
NPI:1619208923
Name:BYWATER, STEPHANIE C (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:BYWATER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 TACOMA DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-5054
Mailing Address - Country:US
Mailing Address - Phone:770-601-6648
Mailing Address - Fax:904-212-0872
Practice Address - Street 1:1988 TACOMA DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-5054
Practice Address - Country:US
Practice Address - Phone:770-601-6648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
NC7377225XP0200X
FLOT 14331225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113199700Medicaid