Provider Demographics
NPI:1518261320
Name:STARZ PEDIATRIC THERAPY NETWORK
Entity Type:Organization
Organization Name:STARZ PEDIATRIC THERAPY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSOM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-726-7337
Mailing Address - Street 1:1302 NW PERSIMMON DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-8628
Mailing Address - Country:US
Mailing Address - Phone:816-726-7337
Mailing Address - Fax:816-847-0218
Practice Address - Street 1:640 NW JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-8278
Practice Address - Country:US
Practice Address - Phone:816-726-7337
Practice Address - Fax:816-847-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518261320Medicaid