Provider Demographics
NPI:1043951957
Name:WALLACE, STACEY (OTRL)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3326 BINSCARTH AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3203
Mailing Address - Country:US
Mailing Address - Phone:989-327-9967
Mailing Address - Fax:
Practice Address - Street 1:5600 WALDO AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6438
Practice Address - Country:US
Practice Address - Phone:989-575-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201011236225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist