Provider Demographics
NPI:1194845875
Name:WALSH, STACEY LYNNE I (COTA)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNNE
Last Name:WALSH
Suffix:I
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:LYNNE
Other - Last Name:DUNLAP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:618 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-3466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4949 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2068
Practice Address - Country:US
Practice Address - Phone:302-998-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU2-0000718224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant