Provider Demographics
NPI:1770795619
Name:DISTEFANO, GEORGIA DENISE (OTR)
Entity type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:DENISE
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:DISTEFANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:19303 WEST 64TH TERRACE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66218
Mailing Address - Country:US
Mailing Address - Phone:913-962-9818
Mailing Address - Fax:
Practice Address - Street 1:6700 ANTIOCH STE 430
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:913-652-9229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1700373225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist