Healthcare Provider Details

I. General information

NPI: 1003478900
Provider Name (Legal Business Name): DOUGLAS REED STEPHENSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 HILLCREST DR
BYRDSTOWN TN
38549-2326
US

IV. Provider business mailing address

38 WORLEY RANCH RD
MONTICELLO KY
42633-3328
US

V. Phone/Fax

Practice location:
  • Phone: 931-864-3162
  • Fax:
Mailing address:
  • Phone: 606-278-2186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA00875
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA03317
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: