Provider Demographics
NPI:1992004949
Name:BROSKI, STACEY (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BROSKI
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-1444
Mailing Address - Country:US
Mailing Address - Phone:402-884-8911
Mailing Address - Fax:
Practice Address - Street 1:1506 PINEWOOD DR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-1444
Practice Address - Country:US
Practice Address - Phone:402-884-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist