Provider Demographics
NPI:1598312514
Name:MACKINTOSH, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MACKINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 LAURANCE CT
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2129
Mailing Address - Country:US
Mailing Address - Phone:410-320-7948
Mailing Address - Fax:
Practice Address - Street 1:12 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3657
Practice Address - Country:US
Practice Address - Phone:410-763-6823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08780225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist