Healthcare Provider Details

I. General information

NPI: 1316770324
Provider Name (Legal Business Name): ERICA SAMPLE STASNY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6884 HICKORY FLAT HWY
WOODSTOCK GA
30188-3229
US

IV. Provider business mailing address

234 PARC DR
CANTON GA
30114-7741
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-8244
  • Fax:
Mailing address:
  • Phone: 803-608-2527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT005760
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: