Provider Demographics
NPI:1477057438
Name:GABOR, STACY MARY (COTA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARY
Last Name:GABOR
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARY
Other - Last Name:SAKOGUCHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1230 S WESTERN AVE APT 115
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-4750
Mailing Address - Country:US
Mailing Address - Phone:714-768-9282
Mailing Address - Fax:
Practice Address - Street 1:3050 N ORMSBY BLVD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-8378
Practice Address - Country:US
Practice Address - Phone:775-841-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV18-1445224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant