Healthcare Provider Details

I. General information

NPI: 1073606786
Provider Name (Legal Business Name): DIANNE MARIE STEFANICK MA.,ATR.,LPAT,B-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 STARLING SQUARE
CLINTON MS
39056
US

IV. Provider business mailing address

5 STARLING SQUARE
CLINTON MS
39056
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-1987
  • Fax:
Mailing address:
  • Phone: 601-924-1987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberPAT0002
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: