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General NPI Number Information
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NPI Number | 1336548783
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Entity Type | Organization
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Legal Business Name | PROSPEROUS LIVING LLC
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 08/21/2014
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Provider Practice Location Address
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Address Line | 1974 CHANDALAR DR SUITE D
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City | PELHAM
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State | AL
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Zip | 35124-4340
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Country | US
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Telephone | 205-358-3515
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Fax |
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Provider Business Mailing Address
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Address Line | 719 HERITAGE PARK LN
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City | HOOVER
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State | AL
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Zip | 35226-4198
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Country | US
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Telephone | 205-266-5394
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Fax | 205-358-3517
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST/PRESIDENT
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Name | STACIE JACKSON
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Credential | OTR/L
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Telephone | 205-266-5394
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XG0600X
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Taxonomy Name | Gerontology Occupational Therapist
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License Number | 2276
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 225XL0004X
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Taxonomy Name | Low Vision Occupational Therapist
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License Number | 2276
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License Number State | AL
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Taxonomy #3
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 2276
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License Number State | AL
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