Provider Demographics
NPI:1851616288
Name:HARDIN, STACIE MICHELLE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:STACIE
Middle Name:MICHELLE
Last Name:HARDIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8120 LINCOLN AVE APT C
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-7232
Mailing Address - Country:US
Mailing Address - Phone:812-303-0069
Mailing Address - Fax:
Practice Address - Street 1:801 S STATE ROAD 57
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4373
Practice Address - Country:US
Practice Address - Phone:812-254-4516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001733A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant