Provider Demographics
NPI:1538533492
Name:SPRAGUE, PAULA (PT)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 KEYSTONE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-4265
Mailing Address - Country:US
Mailing Address - Phone:314-494-5890
Mailing Address - Fax:
Practice Address - Street 1:3001 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2815
Practice Address - Country:US
Practice Address - Phone:386-447-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02180320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO02180OtherLICENSE