Provider Demographics
NPI:1912370412
Name:RICHARDS, STACY LOUISE (MOT/R/L)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LOUISE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:MOT/R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9750 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4449
Mailing Address - Country:US
Mailing Address - Phone:503-256-3920
Mailing Address - Fax:
Practice Address - Street 1:9750 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4449
Practice Address - Country:US
Practice Address - Phone:503-256-3920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR348019225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist