Provider Demographics
NPI:1841799624
Name:STANLEY, TOMMIE W JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:W
Last Name:STANLEY
Suffix:JR
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 1:618A S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5020
Mailing Address - Country:US
Mailing Address - Phone:336-951-6090
Mailing Address - Fax:
Practice Address - Street 1:618A S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5020
Practice Address - Country:US
Practice Address - Phone:336-951-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5929225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant