Healthcare Provider Details

I. General information

NPI: 1184970337
Provider Name (Legal Business Name): STACY LYNN GRISWOLD P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3461 SAINT MARYS RD
WEST TERRE HAUTE IN
47885-9683
US

IV. Provider business mailing address

3461 SAINT MARYS RD
WEST TERRE HAUTE IN
47885-9683
US

V. Phone/Fax

Practice location:
  • Phone: 812-917-5618
  • Fax: 812-917-5618
Mailing address:
  • Phone: 812-917-5618
  • Fax: 812-917-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004465A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: