Provider Demographics
NPI:1154605061
Name:PRIVETT, STEPHANIE RENEE' (PTA)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RENEE'
Last Name:PRIVETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-8132
Mailing Address - Country:US
Mailing Address - Phone:870-931-9357
Mailing Address - Fax:
Practice Address - Street 1:3114 FOX RD
Practice Address - Street 2:STE A
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9322
Practice Address - Country:US
Practice Address - Phone:870-933-9294
Practice Address - Fax:870-933-9293
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1823225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant