Provider Demographics
NPI:1508292681
Name:MCIVOR, STACEY A (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:MCIVOR
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CODFISH HILL RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-3203
Mailing Address - Country:US
Mailing Address - Phone:475-279-0347
Mailing Address - Fax:
Practice Address - Street 1:18 HIGH RISE RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-3836
Practice Address - Country:US
Practice Address - Phone:203-739-5752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003957225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist