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General NPI Number Information
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NPI Number | 1801947510
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Entity Type | Individual
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Provider Name | STACY ELAINE MATTOX OTR
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Gender | Female
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 05/13/2010
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Provider Practice Location Address
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Address Line | 1807 W MOLINE ST
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City | MALVERN
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State | AR
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Zip | 72104-2645
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Country | US
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Telephone | 501-467-3166
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Fax | 501-467-3161
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Provider Business Mailing Address
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Address Line | 913 RIVER ST
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City | BENTON
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State | AR
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Zip | 72015-5024
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Country | US
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Telephone | 501-240-9867
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OTR1458
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License Number State | AR
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