Provider Demographics
NPI:1730853417
Name:STALLARD, CASEY GAIL (COTA/L)
Entity type:Individual
Prefix:MS
First Name:CASEY
Middle Name:GAIL
Last Name:STALLARD
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 1:43 LITTLE WHIM RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-1892
Mailing Address - Country:US
Mailing Address - Phone:703-731-5462
Mailing Address - Fax:
Practice Address - Street 1:11 DAIRY LN
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-2663
Practice Address - Country:US
Practice Address - Phone:540-371-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002086224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant