Provider Demographics
NPI:1902417637
Name:CROSON, STACEY RAE (MOT, OTL)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:RAE
Last Name:CROSON
Suffix:
Gender:F
Credentials:MOT, OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1643
Mailing Address - Country:US
Mailing Address - Phone:812-571-4658
Mailing Address - Fax:
Practice Address - Street 1:1704 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1643
Practice Address - Country:US
Practice Address - Phone:812-571-4658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN315005094A225X00000X
MI5201013903225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist