Basic Information
| Provider Information | |||||||||
| NPI: | 1023438801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELFRIDGE | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SELFRIDGE | ||||||||
| OtherFirstName: | STACIE | ||||||||
| OtherMiddleName: | HAZEL | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | I | ||||||||
| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 NORTHAMPTON STREET | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174339601 | ||||||||
| FaxNumber: | 6174456538 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 NORTHAMPTON STREET | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021184010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174339601 | ||||||||
| FaxNumber: | 6174456538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2014 | ||||||||
| LastUpdateDate: | 10/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 11033 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.