Provider Demographics
NPI:1982176046
Name:BREAUX, STEFANIE (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:BREAUX
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 JENNIFER LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7716
Mailing Address - Country:US
Mailing Address - Phone:318-245-6420
Mailing Address - Fax:
Practice Address - Street 1:403 E FLOURNOY LUCAS RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3906
Practice Address - Country:US
Practice Address - Phone:318-798-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200137225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist