Provider Demographics
NPI:1235326364
Name:STAYNER, SUSAN GAYE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:GAYE
Last Name:STAYNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ORION PL
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-9021
Mailing Address - Country:US
Mailing Address - Phone:360-748-3550
Mailing Address - Fax:
Practice Address - Street 1:1528 PATRICIA AVE
Practice Address - Street 2:APT. # 162
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3491
Practice Address - Country:US
Practice Address - Phone:951-255-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA676224Z00000X
WAOC00000867224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant