Provider Demographics
NPI:1053710459
Name:GUTHRIE, STACEY LYNETTE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNETTE
Last Name:GUTHRIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70885 TWIN BEECH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912-7710
Mailing Address - Country:US
Mailing Address - Phone:740-633-2353
Mailing Address - Fax:740-633-2353
Practice Address - Street 1:70885 TWIN BEECH RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912-7710
Practice Address - Country:US
Practice Address - Phone:740-633-2353
Practice Address - Fax:740-633-2353
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA02733225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064Medicaid