Provider Demographics
NPI:1356628069
Name:ROSS, STACEY J (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:J
Last Name:ROSS
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 1:2 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-6408
Mailing Address - Country:US
Mailing Address - Phone:516-681-5606
Mailing Address - Fax:
Practice Address - Street 1:106 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4047
Practice Address - Country:US
Practice Address - Phone:516-937-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007569225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist