Provider Demographics
NPI:1427221068
Name:COLLINS, STACEY ROSE (PTA)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ROSE
Last Name:COLLINS
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 1:7320 ROGERS AVE STE 26
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4167
Mailing Address - Country:US
Mailing Address - Phone:479-452-7773
Mailing Address - Fax:479-452-7774
Practice Address - Street 1:7320 ROGERS AVE STE 26
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4167
Practice Address - Country:US
Practice Address - Phone:479-452-7773
Practice Address - Fax:479-452-7774
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 1945225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant