Healthcare Provider Details

I. General information

NPI: 1467606343
Provider Name (Legal Business Name): STACIE PORTER BERCK MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3057 LORNA RD
BIRMINGHAM AL
35216-4514
US

IV. Provider business mailing address

1326 NARROWS POINT BND
BIRMINGHAM AL
35242-8676
US

V. Phone/Fax

Practice location:
  • Phone: 205-978-9939
  • Fax:
Mailing address:
  • Phone: 205-980-0393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2465
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: