Provider Demographics
NPI:1841562584
Name:STIDHAM, TABITHA LYNN
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNN
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 CRAFT COLLY RD
Mailing Address - Street 2:
Mailing Address - City:ERMINE
Mailing Address - State:KY
Mailing Address - Zip Code:41815-9025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2531 CRAFT COLLY RD
Practice Address - Street 2:
Practice Address - City:ERMINE
Practice Address - State:KY
Practice Address - Zip Code:41815-9025
Practice Address - Country:US
Practice Address - Phone:606-632-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAO1915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant