Provider Demographics
NPI:1417245648
Name:VOLLENWEIDER, STACEY S (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:S
Last Name:VOLLENWEIDER
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 1:7533 CROOKED STICK DR
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3895
Mailing Address - Country:US
Mailing Address - Phone:228-216-9996
Mailing Address - Fax:601-620-4117
Practice Address - Street 1:311 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3313
Practice Address - Country:US
Practice Address - Phone:601-799-4065
Practice Address - Fax:601-620-4117
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1249225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06524202Medicaid