Provider Demographics
NPI:1942848106
Name:STACKHOUSE, MICHAELA SHELLBY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:SHELLBY
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 SALEM ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-2066
Mailing Address - Country:US
Mailing Address - Phone:201-925-1281
Mailing Address - Fax:
Practice Address - Street 1:32 OSGOOD ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-5411
Practice Address - Country:US
Practice Address - Phone:978-475-3806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13900225X00000X
MA13400225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist