Provider Demographics
NPI:1659078210
Name:BRESHEARS, STEPHANIE LOUISE (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LOUISE
Last Name:BRESHEARS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LOUISE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:MO
Mailing Address - Zip Code:64784-9207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E GENE LATHROP DR
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:MO
Practice Address - Zip Code:64784-9805
Practice Address - Country:US
Practice Address - Phone:417-684-2629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224ZF0002X, 224ZL0004X
MO2019047625224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing
No224ZL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantLow Vision