Provider Demographics
NPI:1881711620
Name:BRAGG, STACY ELIZABETH (OTR)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ELIZABETH
Last Name:BRAGG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 DOLMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-3307
Mailing Address - Country:US
Mailing Address - Phone:314-494-6337
Mailing Address - Fax:888-452-2930
Practice Address - Street 1:634 N MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3733
Practice Address - Country:US
Practice Address - Phone:314-494-6337
Practice Address - Fax:888-452-2930
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.05465225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics