Healthcare Provider Details

I. General information

NPI: 1881711620
Provider Name (Legal Business Name): STACY ELIZABETH BRAGG OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 N MAIN ST SUITE 5
O FALLON IL
62269-3733
US

IV. Provider business mailing address

1433 DOLMAN ST
SAINT LOUIS MO
63104-3307
US

V. Phone/Fax

Practice location:
  • Phone: 314-494-6337
  • Fax: 888-452-2930
Mailing address:
  • Phone: 314-494-6337
  • Fax: 888-452-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.05465
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: