Provider Demographics
NPI:1912123399
Name:LILES, MARY STACY (OTRL)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:STACY
Last Name:LILES
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:STACY
Other - Last Name:LAFON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:4833 STAGHORN CT
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4833 STAGHORN CT
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-4926
Practice Address - Country:US
Practice Address - Phone:407-760-7030
Practice Address - Fax:321-972-5028
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 9254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist