Provider Demographics
NPI:1104045772
Name:PEREGRIN, STEFANIE (OCCUPATIONAL THERAPI)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:PEREGRIN
Suffix:
Gender:F
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2601 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3061
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003259A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200957340Medicaid
IN000000622162OtherANTHEM PROVIDER NUMBER / ARNETT CLINIC, LLC
000000243268OtherANTHEM BLUE CROSS
IN200957340Medicaid
IN815500BB2Medicare PIN