MEDICARE: STACY MILLEN 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	2067546	TX

General Provider Information

NPI Number	:	1538040381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY MILLEN PTA

Provider Business Mailing Address
First Line	:	4409 LONGMEADOW WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7407
Country	:	US
Telephone Number	:	817-875-2777
Fax Number	:

Provider Business Practice Location Address
First Line	:	6931 RIVER PARK CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-8465
Country	:	US
Telephone Number	:	817-731-7611
Fax Number	:

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

Provider Enumeration Date	:	09/09/2025
Last Update Date	:	09/09/2025

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Directions to “ STACY MILLEN PTA” Practice Location

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