Provider Demographics
NPI:1750855540
Name:HENSON, STACEY LEA (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEA
Last Name:HENSON
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 1:620 WARRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5446
Mailing Address - Country:US
Mailing Address - Phone:217-446-0660
Mailing Address - Fax:
Practice Address - Street 1:620 WARRINGTON AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5446
Practice Address - Country:US
Practice Address - Phone:217-446-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009123225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist