Provider Demographics
NPI:1740157791
Name:WARDELL, STEPHANIE MITCHELL (OTA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MITCHELL
Last Name:WARDELL
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 JUSTICIA LOOP
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-2711
Mailing Address - Country:US
Mailing Address - Phone:281-798-2391
Mailing Address - Fax:813-212-3870
Practice Address - Street 1:13540 17TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5244
Practice Address - Country:US
Practice Address - Phone:352-437-5151
Practice Address - Fax:813-212-3870
Is Sole Proprietor?:No
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA20406224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant