Provider Demographics
NPI:1710066618
Name:FISKE, STACY (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FISKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VERNEY DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03047-5000
Mailing Address - Country:US
Mailing Address - Phone:603-547-3311
Mailing Address - Fax:603-547-3232
Practice Address - Street 1:1 VERNEY DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:NH
Practice Address - Zip Code:03047-5000
Practice Address - Country:US
Practice Address - Phone:603-547-3311
Practice Address - Fax:603-547-3232
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0679225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30410650Medicaid