Provider Demographics
NPI:1437400116
Name:STOCKARD, STACY LYN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYN
Last Name:STOCKARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:LYN
Other - Last Name:RAUSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:807 SUNNYHILL LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2085
Mailing Address - Country:US
Mailing Address - Phone:618-219-5473
Mailing Address - Fax:
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-257-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16640225X00000X
IL056.008900225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist