Provider Demographics
NPI:1902201478
Name:RANDALL, STEPHANIE MARIE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CLUB VILLAGE DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9917
Mailing Address - Country:US
Mailing Address - Phone:573-256-2777
Mailing Address - Fax:
Practice Address - Street 1:1100 CLUB VILLAGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4409
Practice Address - Country:US
Practice Address - Phone:573-256-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011001219224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant