Basic Information
Provider Information | |||||||||
NPI: | 1457810582 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEGALL | ||||||||
FirstName: | KYLEE | ||||||||
MiddleName: | BROOKE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | KYLEE | ||||||||
OtherMiddleName: | BROOKE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1628 19TH ST | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794014832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062190500 | ||||||||
FaxNumber: | 8067661286 | ||||||||
Practice Location | |||||||||
Address1: | 1628 19TH ST | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794014832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062190500 | ||||||||
FaxNumber: | 8067661286 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2019 | ||||||||
LastUpdateDate: | 03/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224ZF0002X |   |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Feeding, Eating & Swallowing | 225X00000X | 119867 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.