Provider Demographics
NPI:1962760066
Name:WILLIS, STACEY LATRICE (OTR/L)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LATRICE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 JON STONE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-7536
Mailing Address - Country:US
Mailing Address - Phone:901-461-0621
Mailing Address - Fax:
Practice Address - Street 1:4513 JON STONE LN
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-7536
Practice Address - Country:US
Practice Address - Phone:901-461-0621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2827225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist