MEDICARE: MRS. STEPHANIE G FAVORS OTR/L

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	225X00000X	Occupational Therapist	4103	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4103	OTHER	GA	OT LICENSE

General Provider Information

NPI Number	:	1629005988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE G FAVORS OTR/L

Provider Business Mailing Address
First Line	:	6298 VETERANS PKWY
Second Line	:	SUITE 5A
City	:	COLUMBUS
State	:	GA
Zip	:	31909-6258
Country	:	US
Telephone Number	:	706-322-7762
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 22ND ST
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-4663
Country	:	US
Telephone Number	:	334-298-3401
Fax Number	:

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

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	07/26/2007

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