Provider Demographics
NPI:1003285909
Name:WORM, STACI (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:WORM
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:OSSIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:456 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVID CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68632-1708
Mailing Address - Country:US
Mailing Address - Phone:402-641-1501
Mailing Address - Fax:855-681-9015
Practice Address - Street 1:372 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DAVID CITY
Practice Address - State:NE
Practice Address - Zip Code:68632-2116
Practice Address - Country:US
Practice Address - Phone:402-367-1200
Practice Address - Fax:855-681-9015
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19322083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1932OtherOCCUPATIONAL THERAPIST