Provider Demographics
NPI:1659845774
Name:SWAN, STACY M (COTA)
Entity Type:Individual
Prefix:MISS
First Name:STACY
Middle Name:M
Last Name:SWAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:IL
Mailing Address - Zip Code:62047-0165
Mailing Address - Country:US
Mailing Address - Phone:618-576-9756
Mailing Address - Fax:
Practice Address - Street 1:610 LOWRY ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1768
Practice Address - Country:US
Practice Address - Phone:217-285-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004981224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant