Provider Demographics
NPI:1831517689
Name:STALEY, THOMAS M (DPT)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:STALEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 CADDIE CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-7033
Mailing Address - Country:US
Mailing Address - Phone:859-547-8925
Mailing Address - Fax:
Practice Address - Street 1:1622 CADDIE CIR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-7033
Practice Address - Country:US
Practice Address - Phone:859-547-8925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-30
Last Update Date:2014-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004440174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist