Provider Demographics
NPI:1710569249
Name:STOCKWELL, PAUL (RPGST, CRT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:STOCKWELL
Suffix:
Gender:M
Credentials:RPGST, CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 STRATFORD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8007
Mailing Address - Country:US
Mailing Address - Phone:646-269-9324
Mailing Address - Fax:
Practice Address - Street 1:1990 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3920
Practice Address - Country:US
Practice Address - Phone:321-768-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT16549227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified