Provider Demographics
NPI:1265695423
Name:PELLETIER, STACY A (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:A
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N INGRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65717-9653
Mailing Address - Country:US
Mailing Address - Phone:417-746-0181
Mailing Address - Fax:
Practice Address - Street 1:1604 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1010
Practice Address - Country:US
Practice Address - Phone:417-926-6563
Practice Address - Fax:417-926-1502
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007032812225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist