Provider Demographics
NPI:1598905168
Name:HARRELL, STACI SLAYTON (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:SLAYTON
Last Name:HARRELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:SLAYTON
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1500 E WOODROW WILSON AVE # 117
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON AVE # 117
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2022225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist