Provider Demographics
NPI:1023438801
Name:SELFRIDGE, STACIE (OT)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:
Last Name:SELFRIDGE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MRS
Other - First Name:STACIE
Other - Middle Name:HAZEL
Other - Last Name:SELFRIDGE
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:30 NORTHAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4010
Mailing Address - Country:US
Mailing Address - Phone:617-433-9601
Mailing Address - Fax:617-445-6538
Practice Address - Street 1:30 NORTHAMPTON STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4010
Practice Address - Country:US
Practice Address - Phone:617-433-9601
Practice Address - Fax:617-445-6538
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11033225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist