MEDICARE: STEPHANIE LYNN PHARES MOT,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		IL
2	225X00000X	Occupational Therapist	056011368	IL

General Provider Information

NPI Number	:	1891211348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LYNN PHARES MOT,OTR/L

Provider Business Mailing Address
First Line	:	4450 48TH AVENUE CT
Second Line	:
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-9213
Country	:	US
Telephone Number	:	309-558-0145
Fax Number	:	309-558-0149

Provider Business Practice Location Address
First Line	:	4450 48TH AVENUE CT
Second Line	:
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-9213
Country	:	US
Telephone Number	:	309-558-0145
Fax Number	:	309-558-0149

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

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	07/21/2022

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