Provider Demographics
NPI:1760825780
Name:HAATVEDT, STACY ANN (MA OTR/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:HAATVEDT
Suffix:
Gender:F
Credentials:MA OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2115
Mailing Address - Country:US
Mailing Address - Phone:224-563-4807
Mailing Address - Fax:
Practice Address - Street 1:415 W 8TH ST
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4451
Practice Address - Country:US
Practice Address - Phone:630-323-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.010082225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist