Provider Demographics
NPI:1538640719
Name:ANDERSON, STACIE RENEE (OTR)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 EDINBURGH
Mailing Address - Street 2:
Mailing Address - City:WOODWAY
Mailing Address - State:TX
Mailing Address - Zip Code:76712-4056
Mailing Address - Country:US
Mailing Address - Phone:254-498-1906
Mailing Address - Fax:
Practice Address - Street 1:300 W STATE HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-4041
Practice Address - Country:US
Practice Address - Phone:254-761-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111871225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist