Provider Demographics
NPI:1467687624
Name:HOLLOWAY, STACI STEWART (MPT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:STEWART
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:STEWART
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:363 S DOS CAMINOS AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4734
Mailing Address - Country:US
Mailing Address - Phone:805-654-8544
Mailing Address - Fax:
Practice Address - Street 1:2895 LOMA VISTA RD
Practice Address - Street 2:STE B
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1572
Practice Address - Country:US
Practice Address - Phone:805-643-4093
Practice Address - Fax:805-643-8401
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 21756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA056608OtherMEDICARE PROVIDER ID