MEDICARE: MRS. STACY L WARDEN PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT3627	MS
2	225100000X	Physical Therapist	6079	TN

General Provider Information

NPI Number	:	1831194778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY L WARDEN PT

Provider Business Mailing Address
First Line	:	THE SMITH CLINIC FOR PHYSICAL THERAPY
Second Line	:	7037 HACKS CROSS ROAD
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654
Country	:	US
Telephone Number	:	662-890-7660
Fax Number	:	662-890-7661

Provider Business Practice Location Address
First Line	:	THE SMITH CLINIC FOR PHYSICAL THERAPY
Second Line	:	7037 HACKS CROSS ROAD
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654
Country	:	US
Telephone Number	:	662-890-7660
Fax Number	:	662-890-7661

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/09/2007

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