Provider Demographics
NPI:1740670314
Name:STEWART, TERRICKA (ATC, LAT, MS)
Entity type:Individual
Prefix:
First Name:TERRICKA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:ATC, LAT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HISTORIC 66 E APT 4
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:885 WEST 16TH ST.
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473
Practice Address - Country:US
Practice Address - Phone:573-596-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer