Provider Demographics
NPI:1558996645
Name:MORAN, STACEY E (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:MORAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18184 MILL HOUSE SQ
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-6872
Mailing Address - Country:US
Mailing Address - Phone:585-955-3318
Mailing Address - Fax:
Practice Address - Street 1:44124 WOODRIGE PARKWAY
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-729-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004584225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty