Provider Demographics
NPI:1982123220
Name:PRIDE, STEPHANIE DANIELLE (COTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLE
Last Name:PRIDE
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 1:762 PLAINVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-3118
Mailing Address - Country:US
Mailing Address - Phone:270-584-5429
Mailing Address - Fax:
Practice Address - Street 1:419 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1515
Practice Address - Country:US
Practice Address - Phone:270-821-5564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172404224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty