Provider Demographics
NPI:1023556131
Name:BLEECKER, STACI RAE (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:STACI
Middle Name:RAE
Last Name:BLEECKER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GWINNER
Mailing Address - State:ND
Mailing Address - Zip Code:58040-4001
Mailing Address - Country:US
Mailing Address - Phone:701-678-2244
Mailing Address - Fax:
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4334
Practice Address - Country:US
Practice Address - Phone:701-683-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1260224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant