=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720795677
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY ALLISON STAUBER OTRL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2022
-----------------------------------------------------
Last Update Date | 04/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 DIVISION ST
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-5168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-439-5034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1335 STRASSNER DR
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63144-1872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-502-7996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 5201013100
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------