Provider Demographics
NPI:1023217429
Name:SKINNER, STACY KATHLEEN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:KATHLEEN
Last Name:SKINNER
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 1:7733 FORSYTH BLVD
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1817
Mailing Address - Country:US
Mailing Address - Phone:314-863-7422
Mailing Address - Fax:636-519-7279
Practice Address - Street 1:15201 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-1810
Practice Address - Country:US
Practice Address - Phone:636-532-1515
Practice Address - Fax:636-519-7279
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115313225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant