Provider Demographics
NPI:1568735314
Name:PENNINGTON, STACEY ANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANNE
Other - Last Name:SMOCER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17240 KNAPP ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-2527
Mailing Address - Country:US
Mailing Address - Phone:818-388-6591
Mailing Address - Fax:
Practice Address - Street 1:17650 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1445
Practice Address - Country:US
Practice Address - Phone:818-886-1616
Practice Address - Fax:818-831-8680
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5258225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist