Basic Information
| Provider Information | |||||||||
| NPI: | 1497220941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONROE | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | OTD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BIELENBERG | ||||||||
| OtherFirstName: | STACI | ||||||||
| OtherMiddleName: | RENAE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 113 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970133519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032638903 | ||||||||
| FaxNumber: | 5032668632 | ||||||||
| Practice Location | |||||||||
| Address1: | 2274 SW 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971285597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712612159 | ||||||||
| FaxNumber: | 5038839782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 41084 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.