Healthcare Provider Details

I. General information

NPI: 1205990439
Provider Name (Legal Business Name): PRESTON JOSEPH STELLY JR. P.T., O.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 CYPRESS ST
SULPHUR LA
70663-5050
US

IV. Provider business mailing address

522 CYPRESS ST
SULPHUR LA
70663-5050
US

V. Phone/Fax

Practice location:
  • Phone: 337-533-8410
  • Fax: 337-533-8411
Mailing address:
  • Phone: 337-533-8410
  • Fax: 337-533-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT05159
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1056738
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: