Provider Demographics
NPI:1114236346
Name:WILSON, STACY ALLIEOU (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:ALLIEOU
Last Name:WILSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 WILLOW DR APT 26
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2933
Mailing Address - Country:US
Mailing Address - Phone:336-847-0093
Mailing Address - Fax:208-246-2255
Practice Address - Street 1:4920 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3142
Practice Address - Country:US
Practice Address - Phone:910-585-8308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7684225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist