Provider Demographics
NPI:1801947510
Name:MATTOX, STACY ELAINE (OTR)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ELAINE
Last Name:MATTOX
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-5024
Mailing Address - Country:US
Mailing Address - Phone:501-240-9867
Mailing Address - Fax:
Practice Address - Street 1:1807 W MOLINE ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2645
Practice Address - Country:US
Practice Address - Phone:501-467-3166
Practice Address - Fax:501-467-3161
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1458225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136251721Medicaid