Provider Demographics
NPI:1134342850
Name:SMALLWOOD, STACEY ROBYN (PT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ROBYN
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ROBYN
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:9360 ROYAL MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2067
Mailing Address - Country:US
Mailing Address - Phone:423-316-5336
Mailing Address - Fax:
Practice Address - Street 1:9360 ROYAL MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2067
Practice Address - Country:US
Practice Address - Phone:423-316-5336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT4873225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446652Medicaid
TN3156797OtherBCBS GROUP
TN5441432Medicaid
TN5441432Medicaid