Provider Demographics
NPI:1528829249
Name:STEPHENS, DORRIAN INEZ
Entity type:Individual
Prefix:
First Name:DORRIAN
Middle Name:INEZ
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 BONNIE BRAE CRES
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2028
Mailing Address - Country:US
Mailing Address - Phone:708-717-7677
Mailing Address - Fax:
Practice Address - Street 1:400 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1992
Practice Address - Country:US
Practice Address - Phone:779-707-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.006047224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant