Healthcare Provider Details

I. General information

NPI: 1649465709
Provider Name (Legal Business Name): STACEY ANN WILKS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 MAPLEMOOR LN
WHITE PLAINS NY
10605-4716
US

IV. Provider business mailing address

16 NORTH BROADWAY APT 2B
WHITE PLAINS NY
10601
US

V. Phone/Fax

Practice location:
  • Phone: 347-512-2785
  • Fax:
Mailing address:
  • Phone: 347-512-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number011953-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number011953-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225XR0403X
TaxonomyDriving and Community Mobility Occupational Therapist
License Number011953-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: