Provider Demographics
NPI:1629138482
Name:OESTER, STACY YOUNGBLOOD (OTR)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:YOUNGBLOOD
Last Name:OESTER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 SHADY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-7909
Mailing Address - Country:US
Mailing Address - Phone:706-860-2028
Mailing Address - Fax:
Practice Address - Street 1:444 PARK WEST DRIVE
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813
Practice Address - Country:US
Practice Address - Phone:706-868-6543
Practice Address - Fax:706-868-9579
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003387225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00969482AMedicaid