Provider Demographics
NPI:1003177114
Name:STANLEY, THERESA A (OTR)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:STANLEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9712
Mailing Address - Country:US
Mailing Address - Phone:989-269-8700
Mailing Address - Fax:989-269-8715
Practice Address - Street 1:968 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9712
Practice Address - Country:US
Practice Address - Phone:989-269-8700
Practice Address - Fax:989-269-8715
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1352297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist