Healthcare Provider Details

I. General information

NPI: 1063560696
Provider Name (Legal Business Name): PATRICIA ANN DESTEPHANO OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

IV. Provider business mailing address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

V. Phone/Fax

Practice location:
  • Phone: 904-360-7022
  • Fax:
Mailing address:
  • Phone: 904-360-7022
  • Fax: 904-798-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2348
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberOT 2348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: