Provider Demographics
NPI:1578898300
Name:TRI, STACY NICHOLE (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICHOLE
Last Name:TRI
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:NICHOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:2101 WOODDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2933
Mailing Address - Country:US
Mailing Address - Phone:651-738-9888
Mailing Address - Fax:651-738-9889
Practice Address - Street 1:2101 WOODDALE DR STE A
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2933
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:651-738-9889
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102369225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist