Provider Demographics
NPI:1235647942
Name:BALDWIN, STACIE LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:BALDWIN
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 1:4611 EMMETT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12101 LIESFELD FARM DR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-7097
Practice Address - Country:US
Practice Address - Phone:804-364-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist