Basic Information
| Provider Information | |||||||||
| NPI: | 1629526512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | STACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 E WALNUT AVE | ||||||||
| Address2: | |||||||||
| City: | EUPORA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397442027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622588293 | ||||||||
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| Practice Location | |||||||||
| Address1: | 156 E WALNUT AVE | ||||||||
| Address2: | |||||||||
| City: | EUPORA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397442027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622588293 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT0267 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.