Provider Demographics
NPI:1669239133
Name:GARDNER, STACY J (OT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:J
Other - Last Name:RAUENHORST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:650 N STATE ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-4900
Mailing Address - Country:US
Mailing Address - Phone:208-428-6079
Mailing Address - Fax:
Practice Address - Street 1:650 N STATE ST STE 5
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-4900
Practice Address - Country:US
Practice Address - Phone:208-428-6079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT988225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics