Provider Demographics
NPI:1013373372
Name:POWELL, STACY (LPTA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 VIRGINIA BEACH BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5631
Mailing Address - Country:US
Mailing Address - Phone:804-712-3518
Mailing Address - Fax:
Practice Address - Street 1:5604 VIRGINIA BEACH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5631
Practice Address - Country:US
Practice Address - Phone:804-712-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant