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General NPI Number Information
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NPI Number | 1679562847
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Entity Type | Individual
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Provider Name | STACI L. GOMEZ OTR/CHT
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Gender | Female
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Dates
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Enumeration Date | 10/19/2005
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Last Update Date | 02/24/2025
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Provider Practice Location Address
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Address Line | 700 GENEVA PKWY N
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City | LAKE GENEVA
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State | WI
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Zip | 53147-4594
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Country | US
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Telephone | 262-249-3500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 735044
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City | CHICAGO
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State | IL
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Zip | 60673-5044
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Country | US
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Telephone | 800-326-2250
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XH1200X
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Taxonomy Name | Hand Occupational Therapist
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License Number | 1931-26
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 1931
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License Number State | WI
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