Provider Demographics
NPI:1033323472
Name:LOKKE, STACY LYNN (MS, OTR)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:LOKKE
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8335
Practice Address - Street 1:3746 ROME DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4489
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8702
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003222A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200899150Medicaid
IN000000529049OtherANTHEM PROVIDER NUMBER
IN200899150Medicaid