Provider Demographics
NPI:1134554157
Name:STASELL, ELICIA MARIE (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:ELICIA
Middle Name:MARIE
Last Name:STASELL
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 1:783 STATE ROUTE 18 E
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364
Mailing Address - Country:US
Mailing Address - Phone:815-257-3713
Mailing Address - Fax:
Practice Address - Street 1:6775 PROSPERI DRIVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-478-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003888224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant