Basic Information
| Provider Information | |||||||||
| NPI: | 1124440383 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MARTINELLI | ||||||||
| FirstName: | STACEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17700 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530452006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627813083 | ||||||||
| FaxNumber: | 2627813080 | ||||||||
| Practice Location | |||||||||
| Address1: | 4772 KATELLA AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624308700 | ||||||||
| FaxNumber: | 5624308760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6611 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 1782 | NE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NE | MEDICAID |