Provider Demographics
NPI:1871915793
Name:DOTY, STACY LYNNE (COTA/L)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:LYNNE
Last Name:DOTY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90971 HIGHWAY 101 UNIT 77
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9346
Mailing Address - Country:US
Mailing Address - Phone:503-861-8282
Mailing Address - Fax:
Practice Address - Street 1:90971 HIGHWAY 101 UNIT 77
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9346
Practice Address - Country:US
Practice Address - Phone:503-861-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-11
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR391169224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA391169OtherNATIONAL BOARD FOR CERTIFICATION OIN OCCUPATIONAL THERAPY,INC
OR391169OtherOREGON STATE OCCUPATIONAL THERAPY LICENSE BOARD