Provider Demographics
NPI:1164806147
Name:NICHOLS, STACEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
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 1:2092 DEER CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-5869
Mailing Address - Country:US
Mailing Address - Phone:440-341-4073
Mailing Address - Fax:866-469-3811
Practice Address - Street 1:2092 DEER CROSSING DR
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5869
Practice Address - Country:US
Practice Address - Phone:440-341-4073
Practice Address - Fax:866-469-3811
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.008676225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist