Provider Demographics
NPI:1881963551
Name:FOUKE, STACI LYN (MS, OTR)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LYN
Last Name:FOUKE
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-6585
Mailing Address - Country:US
Mailing Address - Phone:817-550-5058
Mailing Address - Fax:
Practice Address - Street 1:250 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6585
Practice Address - Country:US
Practice Address - Phone:817-550-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114005225X00000X
WA60203284225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1764490-07Medicaid