Provider Demographics
NPI:1649606732
Name:FRAUWIRTH, STACY (OTR/L)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FRAUWIRTH
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 1:3075 ADELINE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2579
Mailing Address - Country:US
Mailing Address - Phone:510-225-7519
Mailing Address - Fax:
Practice Address - Street 1:3075 ADELINE ST STE 120
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703
Practice Address - Country:US
Practice Address - Phone:510-225-7519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT5312225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist