Healthcare Provider Details

I. General information

NPI: 1568586758
Provider Name (Legal Business Name): CHRIS STUBBLEFIELD OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LICK CREEK RD
ANNA IL
62906-3270
US

IV. Provider business mailing address

402 S POPLAR ST
SESSER IL
62884-1710
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-4300
  • Fax:
Mailing address:
  • Phone: 618-625-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056005576
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: