Provider Demographics
NPI:1518570811
Name:GARDNER, STACY LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:PA
Mailing Address - Zip Code:16881-7802
Mailing Address - Country:US
Mailing Address - Phone:814-592-1626
Mailing Address - Fax:
Practice Address - Street 1:384 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:PA
Practice Address - Zip Code:16881-7802
Practice Address - Country:US
Practice Address - Phone:814-592-1626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007578224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant