Healthcare Provider Details

I. General information

NPI: 1780807289
Provider Name (Legal Business Name): STACY SHORE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NW 28TH ST
GAINESVILLE FL
32607-2511
US

IV. Provider business mailing address

379 MAGUIRE VLG APT 6
GAINESVILLE FL
32603-2079
US

V. Phone/Fax

Practice location:
  • Phone: 352-246-5384
  • Fax: 352-376-0126
Mailing address:
  • Phone: 352-846-5492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT7559
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: