Provider Demographics
NPI:1710587100
Name:STOCKMAN, TAYLOR BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BROOKE
Last Name:STOCKMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5446
Mailing Address - Country:US
Mailing Address - Phone:573-876-5888
Mailing Address - Fax:573-876-5878
Practice Address - Street 1:3801 MILLER DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5446
Practice Address - Country:US
Practice Address - Phone:573-876-5888
Practice Address - Fax:573-876-5878
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020002068Medicaid