Provider Demographics
NPI:1811234693
Name:SLAVENS, STACY A (MOTRL)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:SLAVENS
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1003
Mailing Address - Country:US
Mailing Address - Phone:618-282-4969
Mailing Address - Fax:
Practice Address - Street 1:325 SPRING ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1105
Practice Address - Country:US
Practice Address - Phone:618-282-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008965225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist