Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 056008804 | IL |
NPI | 1003846965 |
---|---|
Provider Name | Stacy R Tingley |
First Address | Moweaqua, IL 62550-1019 |
Second Address | Machesney Park, IL 61103-8880 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2006 |
Last Update Date | 11/03/2019 |