MEDICARE: GRACE LEANNE STOCKWELL PTA

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	225200000X	Physical Therapy Assistant	2176693	TX

General Provider Information

NPI Number	:	1851160436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE LEANNE STOCKWELL PTA

Provider Business Mailing Address
First Line	:	134 GROVE LN
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-8744
Country	:	US
Telephone Number	:	903-471-9207
Fax Number	:

Provider Business Practice Location Address
First Line	:	5902 NORTH ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1348
Country	:	US
Telephone Number	:	936-569-6227
Fax Number	:

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

Provider Enumeration Date	:	12/25/2023
Last Update Date	:	12/25/2023

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Directions to “ GRACE LEANNE STOCKWELL PTA” Practice Location

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