=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154496404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY MICHELLE SIZEMORE OTRL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 329 TOWNEPARK CIR 100
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40243-2348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-254-9524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 TOY CT
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40229-6031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-955-5086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | R3019
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------