Healthcare Provider Details

I. General information

NPI: 1205407947
Provider Name (Legal Business Name): STACY BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2021
Last Update Date: 07/04/2021
Certification Date: 07/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E MAIN ST STE 200
WYTHEVILLE VA
24382-3322
US

IV. Provider business mailing address

872 NEW BETHEL RD
WYTHEVILLE VA
24382-3049
US

V. Phone/Fax

Practice location:
  • Phone: 276-525-6043
  • Fax:
Mailing address:
  • Phone: 540-336-1906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119004607
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: