Provider Demographics
NPI:1629581731
Name:HUNT, STACEY A (COTA-L)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:A
Last Name:HUNT
Suffix:
Gender:F
Credentials:COTA-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14441 KEDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2716
Mailing Address - Country:US
Mailing Address - Phone:773-728-8718
Mailing Address - Fax:
Practice Address - Street 1:14441 KEDVALE AVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-2716
Practice Address - Country:US
Practice Address - Phone:773-728-8718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004216224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant