Provider Demographics
NPI:1588019624
Name:PARKS, STACIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:PARKS
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 1:205 VALHALLA DR
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-8509
Mailing Address - Country:US
Mailing Address - Phone:918-348-1779
Mailing Address - Fax:
Practice Address - Street 1:1003 N OKMULGEE AVE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-2502
Practice Address - Country:US
Practice Address - Phone:918-758-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK610224Z00000X
OK5695225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200972050BMedicaid