Healthcare Provider Details

I. General information

NPI: 1093211435
Provider Name (Legal Business Name): STACY KAY CASTLEBERRY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S AVALON ST
WEST MEMPHIS AR
72301-4109
US

IV. Provider business mailing address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

V. Phone/Fax

Practice location:
  • Phone: 870-735-4543
  • Fax: 870-732-4490
Mailing address:
  • Phone: 601-605-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3779
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: