Provider Demographics
NPI:1003093840
Name:WILSON, STACEY BETTCHER
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:BETTCHER
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNNE
Other - Last Name:BETTCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:320 MAIN STREET
Mailing Address - City:WEST NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01985-0956
Mailing Address - Country:US
Mailing Address - Phone:978-363-5553
Mailing Address - Fax:
Practice Address - Street 1:320 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST NEWBURY
Practice Address - State:MA
Practice Address - Zip Code:01985-1420
Practice Address - Country:US
Practice Address - Phone:978-363-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5036225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics