Healthcare Provider Details

I. General information

NPI: 1467810192
Provider Name (Legal Business Name): STACIE MCMILLION
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 GLADE ST
SHADY SPRING WV
25918-9530
US

IV. Provider business mailing address

304 DELRAY DR
SAINT ALBANS WV
25177-3503
US

V. Phone/Fax

Practice location:
  • Phone: 304-228-1525
  • Fax:
Mailing address:
  • Phone: 304-228-1525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberC2051
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: