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General NPI Number Information
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NPI Number | 1518556851
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Entity Type | Individual
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Provider Name | LATISHA STOVALL
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Gender | Female
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Dates
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Enumeration Date | 01/12/2021
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Last Update Date | 01/21/2021
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Provider Practice Location Address
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Address Line | 411 N GRAYSTONE LN
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City | BUSHLAND
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State | TX
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Zip | 79124-1539
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Country | US
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Telephone | 806-787-8610
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 399
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City | BUSHLAND
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State | TX
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Zip | 79012-0399
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0019X
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Taxonomy Name | Physical Rehabilitation Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 111527
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License Number State | TX
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