Provider Demographics
NPI:1760502611
Name:STODDARD, KEITH FREEMAN (PTA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:FREEMAN
Last Name:STODDARD
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 1:1300 STONEHURST DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2951
Mailing Address - Country:US
Mailing Address - Phone:864-231-6238
Mailing Address - Fax:
Practice Address - Street 1:4605 BELTON HWY
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5045
Practice Address - Country:US
Practice Address - Phone:864-261-6734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2085225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant