Provider Demographics
NPI:1083298806
Name:BRYANT, STACEY (COTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 OAK HILL DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2024
Mailing Address - Country:US
Mailing Address - Phone:618-670-3552
Mailing Address - Fax:
Practice Address - Street 1:530 OAK HILL DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2024
Practice Address - Country:US
Practice Address - Phone:618-670-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057-002567224ZF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantFeeding, Eating & Swallowing