MEDICARE: MRS. STEPHANIE JO DETHY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	958866	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200825930	OTHER	IN	FIRST STEPS PROVIDER NUMB
2	958866	OTHER	IN	TEACHER'S LICENSE

General Provider Information

NPI Number	:	1265561708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE JO DETHY

Provider Business Mailing Address
First Line	:	11523 VALLEY FRG
Second Line	:
City	:	SELLERSBURG
State	:	IN
Zip	:	47172-8403
Country	:	US
Telephone Number	:	502-931-7111
Fax Number	:	866-528-4353

Provider Business Practice Location Address
First Line	:	11523 VALLEY FRG
Second Line	:
City	:	SELLERSBURG
State	:	IN
Zip	:	47172-8403
Country	:	US
Telephone Number	:	502-931-7111
Fax Number	:	866-528-4353

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	08/02/2024

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