Provider Demographics
NPI:1558777094
Name:GREEN, STACY LYNN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5278 WHITE DEER RD
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:DE
Mailing Address - Zip Code:19940-3075
Mailing Address - Country:US
Mailing Address - Phone:302-907-0199
Mailing Address - Fax:
Practice Address - Street 1:525 GLENBURN AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1414
Practice Address - Country:US
Practice Address - Phone:410-221-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-04
Last Update Date:2014-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02129224Z00000X
DEU2-0001489224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant