Provider Demographics
NPI:1114486297
Name:CUDDEBACK, STACY (COTA/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:CUDDEBACK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 HAMPDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19604-1004
Mailing Address - Country:US
Mailing Address - Phone:484-638-1023
Mailing Address - Fax:
Practice Address - Street 1:2317 HAMPDEN BLVD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19604-1004
Practice Address - Country:US
Practice Address - Phone:484-638-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP00001985L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant