Provider Demographics
NPI:1902417637
Name:CROSON, STACEY RAE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RAE
Last Name:CROSON
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1372
Mailing Address - Country:US
Mailing Address - Phone:812-571-4658
Mailing Address - Fax:
Practice Address - Street 1:206 E MARION ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1029
Practice Address - Country:US
Practice Address - Phone:574-233-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist