MEDICARE: MRS. STACY SHANETTE SALJOUGHI BA IN KINESIOLOGY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	3747A0650X	Attendant Care Provider
2	347C00000X	Private Vehicle
3	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1558052597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY SHANETTE SALJOUGHI BA IN KINESIOLOGY

Provider Business Mailing Address
First Line	:	136 FLYAWAY LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-1634
Country	:	US
Telephone Number	:	817-891-2471
Fax Number	:

Provider Business Practice Location Address
First Line	:	921 CRAWFORD ST APT 4106
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3481
Country	:	US
Telephone Number	:	817-891-2471
Fax Number	:

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

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	06/19/2025

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