Basic Information
| Provider Information | |||||||||
| NPI: | 1497905251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTICH | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 590 FISHERS STATION DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | VICTOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145649744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859247207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12005 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141039678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857211241 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 006251-1 | NY | N | Other Service Providers | Specialist | 224Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.