=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265553796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY LEBRO D.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1071 CATALINA DR
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-5173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-304-4448
-----------------------------------------------------
Fax | 618-656-8192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1071 CATALINA DR
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-5173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-304-4448
-----------------------------------------------------
Fax | 618-656-8192
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number | SL43410498P
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------