Provider Demographics
NPI:1396433405
Name:BRYHAM, STACEY A
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:A
Last Name:BRYHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 N FALLS CIRCLE DR APT 109
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6841
Mailing Address - Country:US
Mailing Address - Phone:856-839-1447
Mailing Address - Fax:
Practice Address - Street 1:7490 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-3077
Practice Address - Country:US
Practice Address - Phone:856-839-1447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15799224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty