Provider Demographics
NPI:1285879783
Name:TAYLOR, STACY MARIE
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1276 SUZANNE CIR
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:FL
Mailing Address - Zip Code:32564-8402
Mailing Address - Country:US
Mailing Address - Phone:850-682-8388
Mailing Address - Fax:850-682-7463
Practice Address - Street 1:4100 S FERDON BLVD
Practice Address - Street 2:SUITE C-1
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5252
Practice Address - Country:US
Practice Address - Phone:850-682-8388
Practice Address - Fax:850-682-7463
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 8927225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist