Provider Demographics
NPI:1245561083
Name:WILLMON, STACEY M (OT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:WILLMON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 BILL BRADFORD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-4538
Mailing Address - Country:US
Mailing Address - Phone:903-885-5919
Mailing Address - Fax:903-885-9131
Practice Address - Street 1:614 BILL BRADFORD
Practice Address - Street 2:SUITE 101
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4538
Practice Address - Country:US
Practice Address - Phone:903-885-5919
Practice Address - Fax:903-885-9131
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107568225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456789Medicare Oscar/Certification