Provider Demographics
NPI:1851884076
Name:ETHERTON-AGIUS, STACEY ANN (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:ETHERTON-AGIUS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 BROADSTONE RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1950
Mailing Address - Country:US
Mailing Address - Phone:313-212-9722
Mailing Address - Fax:
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-745-0982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001866225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation