Provider Demographics
NPI:1730339862
Name:PHILLIPS, STACY J (MS OTR/L)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GROTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-4540
Mailing Address - Country:US
Mailing Address - Phone:585-359-3710
Mailing Address - Fax:
Practice Address - Street 1:100 GROTON PKWY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623
Practice Address - Country:US
Practice Address - Phone:585-359-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015323-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00357240Medicaid