Healthcare Provider Details

I. General information

NPI: 1154782811
Provider Name (Legal Business Name): MARY THELMA STEWART PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3681 LEAPHART RD STE A
WEST COLUMBIA SC
29169-3068
US

IV. Provider business mailing address

1624 MAIN ST
COLUMBIA SC
29201-2818
US

V. Phone/Fax

Practice location:
  • Phone: 803-454-6090
  • Fax:
Mailing address:
  • Phone: 803-730-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1560
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: