Healthcare Provider Details

I. General information

NPI: 1679757181
Provider Name (Legal Business Name): STACY MARIE BRAULT BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STACY MARIE BRAULT BSW

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8021 CLEAR HAVEN CIR
ANCHORAGE AK
99507-3272
US

IV. Provider business mailing address

PO BOX 231724
ANCHORAGE AK
99523-1724
US

V. Phone/Fax

Practice location:
  • Phone: 907-349-8157
  • Fax: 907-222-1336
Mailing address:
  • Phone: 907-349-8157
  • Fax: 907-222-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number746362
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number746362
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: