Provider Demographics
NPI:1841578531
Name:PHONESAVANH, STEPHANIE BRAY (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:BRAY
Last Name:PHONESAVANH
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 ASHLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666
Mailing Address - Country:US
Mailing Address - Phone:770-725-9856
Mailing Address - Fax:
Practice Address - Street 1:1081 ASHLAND DR
Practice Address - Street 2:
Practice Address - City:STATHAM
Practice Address - State:GA
Practice Address - Zip Code:30666-3403
Practice Address - Country:US
Practice Address - Phone:770-725-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003414225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist