Healthcare Provider Details

I. General information

NPI: 1871100750
Provider Name (Legal Business Name): LAUREN TONOS STAYER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W JACKSON ST STE 2
RIDGELAND MS
39157-2355
US

IV. Provider business mailing address

533 PENNSYLVANIA AVE
JACKSON MS
39216-3212
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-3808
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: