Healthcare Provider Details

I. General information

NPI: 1548457781
Provider Name (Legal Business Name): STANLEY HOUSTON OTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 INTERNATIONAL PKWY #2051
HEATHROW FL
32746-5303
US

IV. Provider business mailing address

4913 PLOMONDON ST APT.# 22
VANCOUVER WA
98661-6163
US

V. Phone/Fax

Practice location:
  • Phone: 800-798-6035
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOC00001252
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: