Provider Demographics
NPI:1851160436
Name:STOCKWELL, GRACE LEANNE (PTA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:LEANNE
Last Name:STOCKWELL
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 1:134 GROVE LN
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-8744
Mailing Address - Country:US
Mailing Address - Phone:903-471-9207
Mailing Address - Fax:
Practice Address - Street 1:5902 NORTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1348
Practice Address - Country:US
Practice Address - Phone:936-569-6227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2176693225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant