Healthcare Provider Details

I. General information

NPI: 1801353040
Provider Name (Legal Business Name): STACEY M OWEN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 LOLA AVE
ALTAVISTA VA
24517-1352
US

IV. Provider business mailing address

105 HILLVIEW DR
LYNCHBURG VA
24502-4107
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-6651
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604926
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: