Provider Demographics
NPI:1083828289
Name:STEWART, STACI NICOLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:NICOLE
Last Name:STEWART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 AIRPORT AVE
Mailing Address - Street 2:BUILDING D
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-5759
Mailing Address - Country:US
Mailing Address - Phone:281-239-1445
Mailing Address - Fax:
Practice Address - Street 1:4706 AIRPORT AVE STE A
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-5645
Practice Address - Country:US
Practice Address - Phone:281-238-1800
Practice Address - Fax:281-239-0828
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11537752251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162299501Medicaid