Healthcare Provider Details

I. General information

NPI: 1104497205
Provider Name (Legal Business Name): ALEXANDRA GRACE STONE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA G ANTHONY OTR/L

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE # 100
JACKSON WY
83001-8640
US

IV. Provider business mailing address

1152 S PARK LOOP RD UNIT E
JACKSON WY
83001-9598
US

V. Phone/Fax

Practice location:
  • Phone: 307-739-1864
  • Fax:
Mailing address:
  • Phone: 770-827-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT007584
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-1577
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: