Provider Demographics
NPI:1457782716
Name:EICKHOLT, STACEY (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:EICKHOLT
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:NIEMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4612 MEADOW VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4519
Mailing Address - Country:US
Mailing Address - Phone:419-303-2565
Mailing Address - Fax:
Practice Address - Street 1:4612 MEADOW VIEW DR
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-4519
Practice Address - Country:US
Practice Address - Phone:419-303-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2021-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.007829225X00000X
TNOT0000004736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist