Provider Demographics
NPI:1083196471
Name:MANSELL, STACY WHITED (PT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:WHITED
Last Name:MANSELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:RENEE
Other - Last Name:WHITED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:950 E COUNTY LINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1928
Mailing Address - Country:US
Mailing Address - Phone:601-308-5117
Mailing Address - Fax:601-308-5103
Practice Address - Street 1:950 E COUNTY LINE RD STE A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1928
Practice Address - Country:US
Practice Address - Phone:601-308-5117
Practice Address - Fax:601-308-5103
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist