Provider Demographics
NPI:1871994053
Name:STANTON, TRACIE (OTA/L)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:STANTON
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 QUAKER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3955
Mailing Address - Country:US
Mailing Address - Phone:860-621-9751
Mailing Address - Fax:
Practice Address - Street 1:27 QUAKER LN
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3955
Practice Address - Country:US
Practice Address - Phone:860-621-9751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000487224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant