Provider Demographics
NPI:1295050912
Name:OTIS, STACIE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:OTIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 PARK ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-3035
Mailing Address - Country:US
Mailing Address - Phone:802-885-4550
Mailing Address - Fax:
Practice Address - Street 1:25 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3050
Practice Address - Country:US
Practice Address - Phone:802-885-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0000358225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant