MEDICARE: MARY THELMA STEWART PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1560	SC

General Provider Information

NPI Number	:	1154782811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY THELMA STEWART PTA

Provider Business Mailing Address
First Line	:	1624 MAIN ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-2818
Country	:	US
Telephone Number	:	803-730-8105
Fax Number	:

Provider Business Practice Location Address
First Line	:	3681 LEAPHART RD STE A
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3068
Country	:	US
Telephone Number	:	803-454-6090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2016
Last Update Date	:	03/09/2016

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