Healthcare Provider Details

I. General information

NPI: 1669726626
Provider Name (Legal Business Name): STACY MARIE STUCKE COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 E CENTRAL ST
UNION CITY OH
45390-1605
US

IV. Provider business mailing address

147 CHURCH ST
OSGOOD OH
45351
US

V. Phone/Fax

Practice location:
  • Phone: 937-968-5284
  • Fax:
Mailing address:
  • Phone: 419-852-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number03718
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: