Provider Demographics
NPI:1720078306
Name:TEODOSIO, STEPHANIE J (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:J
Last Name:TEODOSIO
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:J
Other - Last Name:KACIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:533 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3218
Mailing Address - Country:US
Mailing Address - Phone:330-297-9020
Mailing Address - Fax:330-297-9095
Practice Address - Street 1:6847 N CHESTNUT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-2770
Practice Address - Fax:330-297-8833
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1002046225X00000X
OH003544225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH003544OtherOHIO OT PT ATC BOARD