Provider Demographics
NPI:1891211348
Name:PHARES, STEPHANIE LYNN (MOT,OTR/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:PHARES
Suffix:
Gender:F
Credentials:MOT,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 48TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-9213
Mailing Address - Country:US
Mailing Address - Phone:309-558-0145
Mailing Address - Fax:309-558-0149
Practice Address - Street 1:4450 48TH AVENUE CT
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-9213
Practice Address - Country:US
Practice Address - Phone:309-558-0145
Practice Address - Fax:309-558-0149
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
IL056011368225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist