Provider Demographics
NPI:1497250443
Name:STALLIS, COURTNEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:STALLIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 GOLFWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6346
Mailing Address - Country:US
Mailing Address - Phone:314-814-5192
Mailing Address - Fax:
Practice Address - Street 1:324 JUNGERMANN RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-5350
Practice Address - Country:US
Practice Address - Phone:636-928-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics