MEDICARE: MS. LEEANN STANLEY PT

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	208100000X	Physical Medicine & Rehabilitation Physician		IL

General Provider Information

NPI Number	:	1982704995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LEEANN STANLEY PT

Provider Business Mailing Address
First Line	:	PO BOX 503861
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63150-0001
Country	:	US
Telephone Number	:	618-241-2128
Fax Number	:	618-241-3848

Provider Business Practice Location Address
First Line	:	8 CUSUMANO PROFESSIONAL PLAZA DR
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6736
Country	:	US
Telephone Number	:	618-241-2128
Fax Number	:	618-241-3848

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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