Provider Demographics
NPI:1063073005
Name:WHALEN, STEFANIE BREANNE (COTA/ T OT)
Entity type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:BREANNE
Last Name:WHALEN
Suffix:
Gender:F
Credentials:COTA/ T OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 DIXON PKWY
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9567
Mailing Address - Country:US
Mailing Address - Phone:219-707-6511
Mailing Address - Fax:
Practice Address - Street 1:1348 DIXON PKWY
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9567
Practice Address - Country:US
Practice Address - Phone:219-707-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002593A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN927215735OtherPRIVATE INSURANCE