Provider Demographics
NPI:1720433741
Name:RICKRODE, STEPHANIE (OT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:RICKRODE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 ALT 19 STE A
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5363
Mailing Address - Country:US
Mailing Address - Phone:727-773-2687
Mailing Address - Fax:277-773-2742
Practice Address - Street 1:2150 ALT 19 STE A
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5363
Practice Address - Country:US
Practice Address - Phone:727-773-2687
Practice Address - Fax:277-773-2742
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17636225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017352000Medicaid