Provider Demographics
NPI:1750855789
Name:COLE-LARSON, STACEY MICHELE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MICHELE
Last Name:COLE-LARSON
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 1:61 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 W HUDSON AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1609
Practice Address - Country:US
Practice Address - Phone:201-871-8882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09025000224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant