Organization
PROSPEROUS LIVING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
STACIE JACKSON OTR/L (OCCUPATIONAL THERAPIST/PRESIDENT)
(205) 266-5394
Entity
Organization
Contact information
Practice address
1974 CHANDALAR DR, SUITE D, PELHAM, AL 35124-4340
(205) 358-3515
Mailing address
719 HERITAGE PARK LN, HOOVER, AL 35226-4198
(205) 266-5394
(205) 358-3517
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
2276
AL
225XG0600X
Gerontology Occupational Therapist
2276
AL
225XL0004X
Low Vision Occupational Therapist
2276
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2276
OCCUPATIONAL THERAPIST
AL
Enumeration date
08/21/2014
Last updated
08/21/2014
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