Provider Demographics
NPI:1215651856
Name:STEWART, CONNIE LYNN (PTA 002094)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LYNN
Last Name:STEWART
Suffix:
Gender:F
Credentials:PTA 002094
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6960
Mailing Address - Country:US
Mailing Address - Phone:240-321-4532
Mailing Address - Fax:
Practice Address - Street 1:511 BURROUGHS ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-0307
Practice Address - Country:US
Practice Address - Phone:304-285-5500
Practice Address - Fax:304-285-2787
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002094225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant