Provider Demographics
NPI:1386777696
Name:LEONARD, STACY (MSPT)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 MAYFLOWER LN APT B
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-2795
Mailing Address - Country:US
Mailing Address - Phone:870-534-7392
Mailing Address - Fax:870-534-7297
Practice Address - Street 1:3450 W 34TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5508
Practice Address - Country:US
Practice Address - Phone:870-534-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT#1951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist