Provider Demographics
NPI:1972152478
Name:WIEN, STACY BETH (COTA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:BETH
Last Name:WIEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18504 BOTHELL WAY NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-1927
Mailing Address - Country:US
Mailing Address - Phone:425-481-1933
Mailing Address - Fax:425-527-6948
Practice Address - Street 1:18504 BOTHELL WAY NE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1927
Practice Address - Country:US
Practice Address - Phone:425-481-1933
Practice Address - Fax:425-527-6948
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60865959224Z00000X
AZ407038224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB35998Medicaid