Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OTA02733 | OH |
NPI | 1053710459 |
---|---|
Provider Name | Stacey Lynette Guthrie |
First Address | Bridgeport, OH 43912-7710 |
Second Address | Bridgeport, OH 43912-7710 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2014 |
Last Update Date | 21/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0064 | (05) | OH |