Provider Demographics
NPI:1962656207
Name:GREEN, STACEY EMMA
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:EMMA
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 FORT JOHNSON ROAD
Mailing Address - Street 2:JAMES ISLAND CHARTER HIGH SCHOOL
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412
Mailing Address - Country:US
Mailing Address - Phone:843-762-2754
Mailing Address - Fax:843-762-5228
Practice Address - Street 1:1000 FORT JOHNSON ROAD
Practice Address - Street 2:JAMES ISLAND CHARTER HIGH SCHOOL
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412
Practice Address - Country:US
Practice Address - Phone:843-762-2754
Practice Address - Fax:843-762-5228
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1469225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist