Provider Demographics
NPI:1578597019
Name:THOMAS, STACY (OT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N RICHARD JACKSON BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2521
Mailing Address - Country:US
Mailing Address - Phone:850-235-6360
Mailing Address - Fax:850-235-8871
Practice Address - Street 1:120 N RICHARD JACKSON BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32407-2521
Practice Address - Country:US
Practice Address - Phone:850-235-6360
Practice Address - Fax:850-235-8871
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT0005631225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL885913200Medicaid