Provider Demographics
NPI:1609924802
Name:HAHN, STACY (OTRL)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HAHN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 CHICOT DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7382
Mailing Address - Country:US
Mailing Address - Phone:501-329-8815
Mailing Address - Fax:
Practice Address - Street 1:2740 COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-9310
Practice Address - Country:US
Practice Address - Phone:501-329-5459
Practice Address - Fax:501-327-1738
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR865225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W692Medicare ID - Type UnspecifiedBLUE CROSS BLUE SHIELD