Provider Demographics
NPI:1336548783
Name:PROSPEROUS LIVING LLC
Entity type:Organization
Organization Name:PROSPEROUS LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:205-266-5394
Mailing Address - Street 1:719 HERITAGE PARK LN
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-4198
Mailing Address - Country:US
Mailing Address - Phone:205-266-5394
Mailing Address - Fax:205-358-3517
Practice Address - Street 1:1974 CHANDALAR DR
Practice Address - Street 2:SUITE D
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-4340
Practice Address - Country:US
Practice Address - Phone:205-358-3515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2276225X00000X, 225XG0600X, 225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontologyGroup - Single Specialty
No225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2276OtherOCCUPATIONAL THERAPIST