Provider Demographics
NPI:1598871030
Name:WILLIAMS, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WILLIAMS
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 1:907 BALA LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4951
Mailing Address - Country:US
Mailing Address - Phone:310-392-5784
Mailing Address - Fax:
Practice Address - Street 1:2001 S 17TH ST
Practice Address - Street 2:STE 101
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6628
Practice Address - Country:US
Practice Address - Phone:910-763-8184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3729OtherLICENSE #