Provider Demographics
NPI:1598163511
Name:WILSON, STACI TIBBS (OTR, MOT, CHES)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:TIBBS
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR, MOT, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 SHADOW CREEK PKWY STE 111-216
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7283
Mailing Address - Country:US
Mailing Address - Phone:713-280-3663
Mailing Address - Fax:855-710-7269
Practice Address - Street 1:13212 LONE CREEK LN
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-3476
Practice Address - Country:US
Practice Address - Phone:713-280-3663
Practice Address - Fax:855-710-7269
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XG0600X, 225XN1300X
TX112297225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation