Provider Demographics
NPI:1376050302
Name:STAMBAUGH, MARY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:STAMBAUGH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:STAMBAUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:5305 SUNDANCE MOUNTAIN CIR
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-8600
Mailing Address - Country:US
Mailing Address - Phone:719-502-1775
Mailing Address - Fax:
Practice Address - Street 1:3155 AVENUE C
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-8109
Practice Address - Country:US
Practice Address - Phone:406-690-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PTA-LIC-13170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant