Provider Demographics
NPI:1124440383
Name:MARTINELLI, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MARTINELLI
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 1:17700 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2006
Mailing Address - Country:US
Mailing Address - Phone:262-781-3083
Mailing Address - Fax:262-781-3080
Practice Address - Street 1:4772 KATELLA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2600
Practice Address - Country:US
Practice Address - Phone:562-430-8700
Practice Address - Fax:562-430-8760
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6611225X00000X
NE1782225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEPENDINGMedicaid