Provider Demographics
NPI:1952471088
Name:STACKEWICZ, DAWN MARIE (MS OTRL)
Entity Type:Individual
Prefix:MISS
First Name:DAWN
Middle Name:MARIE
Last Name:STACKEWICZ
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:M
Other - Last Name:STACKEWICZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2000 W COMMERCIAL BOULEVARD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309
Mailing Address - Country:US
Mailing Address - Phone:954-351-0511
Mailing Address - Fax:954-351-0411
Practice Address - Street 1:2000 W COMMERCIAL BOULEVARD
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309
Practice Address - Country:US
Practice Address - Phone:954-351-0511
Practice Address - Fax:954-351-0411
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG427ZOtherMEDICARE PTAN
FLAG243OtherMEDICARE PTAN GROUP