Provider Demographics
NPI:1104497205
Name:STONE, ALEXANDRA GRACE (OTR/L)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:GRACE
Last Name:STONE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:G
Other - Last Name:ANTHONY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1152 S PARK LOOP RD UNIT E
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9598
Mailing Address - Country:US
Mailing Address - Phone:770-827-0330
Mailing Address - Fax:
Practice Address - Street 1:555 E BROADWAY AVE # 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-1864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007584225X00000X
WYOT-1577225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist