Healthcare Provider Details

I. General information

NPI: 1518371863
Provider Name (Legal Business Name): STACY HALL BRINK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2014
Last Update Date: 06/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4713 E MICHIGAN AVE
PHOENIX AZ
85032-9517
US

IV. Provider business mailing address

4713 E MICHIGAN AVE
PHOENIX AZ
85032-9517
US

V. Phone/Fax

Practice location:
  • Phone: 602-369-0325
  • Fax:
Mailing address:
  • Phone: 602-369-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAZ00058
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: