Healthcare Provider Details

I. General information

NPI: 1144157322
Provider Name (Legal Business Name): STEPHANIE TEAGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LIZZIE ST
SAN LUIS OBISPO CA
93401-3062
US

IV. Provider business mailing address

1826 SAN LUIS RANCH RD
SAN LUIS OBISPO CA
93405-1566
US

V. Phone/Fax

Practice location:
  • Phone: 805-549-1220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number13860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: