Provider Demographics
NPI:1538558705
Name:WELLS, STACEY RENEE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:RENEE
Last Name:WELLS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19165 S 4210 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-4290
Mailing Address - Country:US
Mailing Address - Phone:918-231-1758
Mailing Address - Fax:
Practice Address - Street 1:4350 WILL ROGERS PKWY
Practice Address - Street 2:SUITE 600
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-1826
Practice Address - Country:US
Practice Address - Phone:405-246-6674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK434224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant