Provider Demographics
NPI:1245205905
Name:STOCKDALE, MYRA ANN (DHSC, ATC, LAT)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:ANN
Last Name:STOCKDALE
Suffix:
Gender:F
Credentials:DHSC, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E GRUNDY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-1114
Mailing Address - Country:US
Mailing Address - Phone:812-599-1263
Mailing Address - Fax:502-272-7614
Practice Address - Street 1:2001 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1863
Practice Address - Country:US
Practice Address - Phone:502-272-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000285A2255A2300X
KYAT13472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer