Provider Demographics
NPI:1891335279
Name:STOVALL, GESSICA DIAN (OTD)
Entity type:Individual
Prefix:DR
First Name:GESSICA
Middle Name:DIAN
Last Name:STOVALL
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9644 S KALINA WAY
Mailing Address - Street 2:APT 207
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-1237
Mailing Address - Country:US
Mailing Address - Phone:504-234-0241
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:504-234-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11511725-4201225XE0001X, 225XE1200X, 225XG0600X, 225XL0004X, 225XM0800X, 225XN1300X, 225XP0019X, 225XP0200X, 225XR0403X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility