Provider Demographics
NPI:1881103885
Name:WILSON, STACY J (OTA/L)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 E SEMORAN BLVD
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-6062
Mailing Address - Country:US
Mailing Address - Phone:407-862-6263
Mailing Address - Fax:407-862-4188
Practice Address - Street 1:3355 E SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-6062
Practice Address - Country:US
Practice Address - Phone:407-862-6263
Practice Address - Fax:407-862-4188
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8497224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant