Healthcare Provider Details

I. General information

NPI: 1467181644
Provider Name (Legal Business Name): MCKENNA AVERY STOCKTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MCKENNA AVERY STANLEY

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 S BELT LINE RD STE 140
COPPELL TX
75019-7610
US

IV. Provider business mailing address

2305 ERICA WAY
LEWISVILLE TX
75067-6744
US

V. Phone/Fax

Practice location:
  • Phone: 972-745-9060
  • Fax:
Mailing address:
  • Phone: 210-643-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1360726
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: