Provider Demographics
NPI:1033691209
Name:BRYANT, STACIE FARR (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:FARR
Last Name:BRYANT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:GOODMAN
Other - Last Name:FARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3302 E GIBRALTAR AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-2642
Mailing Address - Country:US
Mailing Address - Phone:801-971-7987
Mailing Address - Fax:
Practice Address - Street 1:3302 E GIBRALTAR AVE
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-2642
Practice Address - Country:US
Practice Address - Phone:801-971-7987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11701688-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist