Provider Demographics
NPI:1750971644
Name:BEATTY, STACEY E (MSOT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:BEATTY
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 IYANOUGH RD
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-4728
Mailing Address - Country:US
Mailing Address - Phone:774-487-7513
Mailing Address - Fax:
Practice Address - Street 1:111 HEADWATERS DR
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-1028
Practice Address - Country:US
Practice Address - Phone:508-430-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13669225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist