Provider Demographics
NPI:1720314628
Name:WAYNE, STACEY BORODKIN (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:BORODKIN
Last Name:WAYNE
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 1:9 ELMWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1401
Mailing Address - Country:US
Mailing Address - Phone:860-953-1204
Mailing Address - Fax:
Practice Address - Street 1:9 ELMWOOD CT
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1401
Practice Address - Country:US
Practice Address - Phone:860-953-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2991225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist