=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770795619
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGIA DENISE DISTEFANO OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 ANTIOCH STE 430
-----------------------------------------------------
City | MERRIAM
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-652-9229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19303 WEST 64TH TERRACE
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-962-9818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 1700373
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------