Provider Demographics
NPI:1790385904
Name:MOSS, STEPHANIE E (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:MOSS
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 1:1200 CORPORATE DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242
Mailing Address - Country:US
Mailing Address - Phone:423-206-4158
Mailing Address - Fax:717-773-4654
Practice Address - Street 1:2340 NW 32ND ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065-6589
Practice Address - Country:US
Practice Address - Phone:405-396-3322
Practice Address - Fax:405-392-3356
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2021225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant