=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174576128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY ANN KOSCINSKI MSPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 12/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4009 BELLAIRE BLVD SUITE M
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-669-0042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12727 KIMBERLEY LN STE 103
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-4047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-365-9338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physical Therapist
-----------------------------------------------------
License Number | 1144210
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------