Provider Demographics
NPI:1689432718
Name:STACY, MICHELLE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:STACY
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 1:4304 E 205TH ST
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-9237
Mailing Address - Country:US
Mailing Address - Phone:816-509-6227
Mailing Address - Fax:
Practice Address - Street 1:4304 E 205TH ST
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-9237
Practice Address - Country:US
Practice Address - Phone:816-509-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027967224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant