Provider Demographics
NPI:1346596913
Name:STACEY, JAMES LEE (COTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LEE
Last Name:STACEY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 HOWE AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3305
Mailing Address - Country:US
Mailing Address - Phone:916-564-5010
Mailing Address - Fax:
Practice Address - Street 1:1337 HOWE AVE STE 107
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3305
Practice Address - Country:US
Practice Address - Phone:916-564-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN636224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2592OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY
TN636OtherCOTA