Basic Information
| Provider Information | |||||||||
| NPI: | 1003944240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STODDART | ||||||||
| FirstName: | LAUREN | ||||||||
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| Credential: | OCCUPATIONAL THERP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 E. 24TH ST | ||||||||
| Address2: | P.O. BOX 4588 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778054588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 E 24TH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778035303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798226467 | ||||||||
| FaxNumber: | 9798219448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 107005 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 005330801 | 05 | TX | MEDICAID |