MEDICARE: MRS. STACIE LEIGH SITES MOT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	888	WV

General Provider Information

NPI Number	:	1104118348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACIE LEIGH SITES MOT

Provider Business Mailing Address
First Line	:	PO BOX 1019
Second Line	:
City	:	PETERSBURG
State	:	WV
Zip	:	26847-1019
Country	:	US
Telephone Number	:	304-257-1026
Fax Number	:	304-257-9712

Provider Business Practice Location Address
First Line	:	1 HOSPITAL DR
Second Line	:
City	:	PETERSBURG
State	:	WV
Zip	:	26847-9549
Country	:	US
Telephone Number	:	304-257-1026
Fax Number	:	304-257-9712

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2011
Last Update Date	:	05/06/2011

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