Healthcare Provider Details

I. General information

NPI: 1518368638
Provider Name (Legal Business Name): STACEY WARREN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PIPER RD
SCARBOROUGH ME
04074-7575
US

IV. Provider business mailing address

702 OCEAN AVE APT 1
PORTLAND ME
04103-2799
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-8700
  • Fax:
Mailing address:
  • Phone: 860-490-0318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT4253
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number004002
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: