=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225740418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIELLE STANLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2022
-----------------------------------------------------
Last Update Date | 12/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 W MEYER RD
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385-3499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-887-3660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 KENMOOR AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 28461
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 39701
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------