Healthcare Provider Details

I. General information

NPI: 1134442726
Provider Name (Legal Business Name): APPLETREE THERAPY SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2010
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

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

V. Phone/Fax

Practice location:
  • Phone: 618-690-0068
  • Fax:
Mailing address:
  • Phone: 618-690-0068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number056005465
License Number StateIL

VIII. Authorized Official

Name: STACY E BRAGG
Title or Position: MANAGING MEMBER
Credential: MS OTR/L
Phone: 314-494-6337