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
| State | License ID | Taxonomies |
|---|---|---|
| UT | 11511725-4201 | 225XE0001X, 225XE1200X, 225XG0600X, 225XL0004X, 225XM0800X, 225XN1300X, 225XP0019X, 225XP0200X, 225XR0403X, 225X00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | |
| No | 225XE0001X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Environmental Modification |
| No | 225XE1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics |
| No | 225XG0600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology |
| No | 225XL0004X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Low Vision |
| No | 225XM0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Mental Health |
| No | 225XN1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Neurorehabilitation |
| No | 225XP0019X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
| No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
| No | 225XR0403X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Driving and Community Mobility |
