Provider Demographics
NPI:1689000275
Name:ABBITT, STACIE LYN (COTA)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:LYN
Last Name:ABBITT
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 1:1111 E TOWNLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3038
Mailing Address - Country:US
Mailing Address - Phone:602-743-8489
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7086
Practice Address - Country:US
Practice Address - Phone:800-684-8049
Practice Address - Fax:800-325-1326
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60341837224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant