Provider Demographics
NPI:1467701250
Name:STORY, CHARLES P (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:P
Last Name:STORY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 E COLUMBIA # 25
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753
Mailing Address - Country:US
Mailing Address - Phone:870-234-3996
Mailing Address - Fax:
Practice Address - Street 1:191 E COLUMBIA # 25
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-234-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2665225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225200000XMedicaid