Provider Demographics
NPI:1710524608
Name:RODRIGUEZ, STACIE ANN (LOT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:ANN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 KIRKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-1752
Mailing Address - Country:US
Mailing Address - Phone:214-675-1233
Mailing Address - Fax:
Practice Address - Street 1:909 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1520
Practice Address - Country:US
Practice Address - Phone:214-820-9359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist