Provider Demographics
NPI:1104071679
Name:MATZELLE, STACIE (OTR/L, MS)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:MATZELLE
Suffix:
Gender:F
Credentials:OTR/L, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-3202
Mailing Address - Country:US
Mailing Address - Phone:718-386-8854
Mailing Address - Fax:
Practice Address - Street 1:6026 59TH AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-3202
Practice Address - Country:US
Practice Address - Phone:718-386-8854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014846-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics