Provider Demographics
NPI:1528029832
Name:EDWARDS, STACIA LYNN (BS, MOT, OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:STACIA
Middle Name:LYNN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:BS, MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18674 CAMINITO CANTILENA
Mailing Address - Street 2:# 237
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-6127
Mailing Address - Country:US
Mailing Address - Phone:619-252-5762
Mailing Address - Fax:
Practice Address - Street 1:11665 AVENA PL
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2421
Practice Address - Country:US
Practice Address - Phone:858-673-5437
Practice Address - Fax:858-673-5434
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 7498225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics