Healthcare Provider Details

I. General information

NPI: 1336548783
Provider Name (Legal Business Name): PROSPEROUS LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1974 CHANDALAR DR SUITE D
PELHAM AL
35124-4340
US

IV. Provider business mailing address

719 HERITAGE PARK LN
HOOVER AL
35226-4198
US

V. Phone/Fax

Practice location:
  • Phone: 205-358-3515
  • Fax:
Mailing address:
  • Phone: 205-266-5394
  • Fax: 205-358-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number2276
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number2276
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2276
License Number StateAL

VIII. Authorized Official

Name: STACIE JACKSON
Title or Position: OCCUPATIONAL THERAPIST/PRESIDENT
Credential: OTR/L
Phone: 205-266-5394