Provider Demographics
NPI:1871986976
Name:STUBBLEFIELD, MARIAH (MSOTR/L)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14840 STATE HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-4712
Mailing Address - Country:US
Mailing Address - Phone:618-218-5006
Mailing Address - Fax:
Practice Address - Street 1:14840 STATE HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-4712
Practice Address - Country:US
Practice Address - Phone:618-218-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009881225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist