Provider Demographics
NPI:1497905251
Name:COSTICH, STACEY M (OTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:COSTICH
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 FISHERS STATION DR STE 130
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9744
Mailing Address - Country:US
Mailing Address - Phone:585-924-7207
Mailing Address - Fax:
Practice Address - Street 1:12005 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-9678
Practice Address - Country:US
Practice Address - Phone:585-721-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006251-1174400000X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No174400000XOther Service ProvidersSpecialist