MEDICARE: STACY OVERSTREET 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

General Provider Information

NPI Number	:	1609378389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY OVERSTREET PTA

Provider Business Mailing Address
First Line	:	111 MARK DANIELS CIR
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-9734
Country	:	US
Telephone Number	:	954-895-2526
Fax Number	:	954-895-2526

Provider Business Practice Location Address
First Line	:	111 MARK DANIELS CIR
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-9734
Country	:	US
Telephone Number	:	954-895-2526
Fax Number	:	954-895-2526

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

Provider Enumeration Date	:	03/08/2018
Last Update Date	:	03/08/2018

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Directions to “ STACY OVERSTREET PTA” Practice Location

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