Provider Demographics
NPI:1881785962
Name:MASTEN, STEFANI R (OT)
Entity type:Individual
Prefix:MISS
First Name:STEFANI
Middle Name:R
Last Name:MASTEN
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 1:2406 VILLA CT
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1946
Mailing Address - Country:US
Mailing Address - Phone:903-962-7901
Mailing Address - Fax:903-962-3082
Practice Address - Street 1:5609 DONNYBROOK AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6111
Practice Address - Country:US
Practice Address - Phone:903-962-7901
Practice Address - Fax:903-962-3082
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110412225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85854OtherBLUE CROSS BLUE LINK NUMB
TX8T2034OtherBLUE CROSS PAR PLAN NUMBE