Healthcare Provider Details

I. General information

NPI: 1053558494
Provider Name (Legal Business Name): STACEY MICHELE PHILLIPS MS, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 W COLT SQUARE DR
FAYETTEVILLE AR
72703-2813
US

IV. Provider business mailing address

46 W COLT SQUARE DR
FAYETTEVILLE AR
72703-2813
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-2740
  • Fax: 479-582-2746
Mailing address:
  • Phone: 479-582-2740
  • Fax: 479-582-2746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 2212
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: