Provider Demographics
NPI:1508013939
Name:STONE, GEORGIA DIANE
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:DIANE
Last Name:STONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 DOVE MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6625
Mailing Address - Country:US
Mailing Address - Phone:601-427-0641
Mailing Address - Fax:
Practice Address - Street 1:1076 CHAMBLISS RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6381
Practice Address - Country:US
Practice Address - Phone:901-348-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1624224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant