Provider Demographics
NPI:1679562847
Name:GOMEZ, STACI L (OTR/CHT)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:L
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:OTR/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1040
Mailing Address - Country:US
Mailing Address - Phone:262-210-1431
Mailing Address - Fax:
Practice Address - Street 1:3033 W LAYTON AVE STE 202
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2621
Practice Address - Country:US
Practice Address - Phone:414-647-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1931-26225XH1200X
WI1931-026225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand