Provider Demographics
NPI:1457953002
Name:TUCKER, STEPHANIE NICHOLE (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICHOLE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N HORN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-1847
Mailing Address - Country:US
Mailing Address - Phone:618-579-6399
Mailing Address - Fax:
Practice Address - Street 1:1301 E DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-3846
Practice Address - Country:US
Practice Address - Phone:618-997-1365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
IL057.005508224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant