Provider Demographics
NPI:1942944830
Name:STEFAN, NICOLE MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:STEFAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PAUL BRAUN CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3830
Mailing Address - Country:US
Mailing Address - Phone:203-444-8817
Mailing Address - Fax:
Practice Address - Street 1:2505 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-2419
Practice Address - Country:US
Practice Address - Phone:203-444-8817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5958225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics