Provider Demographics
NPI:1326383688
Name:LARSON, STACY LYNN
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:251 TIMBERS BLUFF TRL
Mailing Address - Street 2:
Mailing Address - City:BEECHER
Mailing Address - State:IL
Mailing Address - Zip Code:60401-5112
Mailing Address - Country:US
Mailing Address - Phone:708-946-9809
Mailing Address - Fax:
Practice Address - Street 1:19015 S JODI RD STE A
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8534
Practice Address - Country:US
Practice Address - Phone:708-478-7786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057000615225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057000615OtherCERTIFED OCCUPATIONAL THERAPY ASSISTANT