Provider Demographics
NPI:1134768708
Name:MABUS, STEPHANIE LEE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEE
Last Name:MABUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15248 COUNTRY LAKE ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:IL
Mailing Address - Zip Code:62640-7285
Mailing Address - Country:US
Mailing Address - Phone:618-292-3035
Mailing Address - Fax:
Practice Address - Street 1:873 GORVE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-479-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003071224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant