Provider Demographics
NPI:1780058925
Name:STINE, STACEY MARIE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARIE
Last Name:STINE
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 1:98 HOSPITALITY DR
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-5360
Mailing Address - Country:US
Mailing Address - Phone:802-488-0909
Mailing Address - Fax:
Practice Address - Street 1:98 HOSPITALITY DR
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-5360
Practice Address - Country:US
Practice Address - Phone:802-488-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-28
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT073.0000187224Z00000X
NV17-1423224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant