Provider Demographics
NPI:1831194778
Name:WARDEN, STACY L (PT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:L
Last Name:WARDEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:THE SMITH CLINIC FOR PHYSICAL THERAPY
Mailing Address - Street 2:7037 HACKS CROSS ROAD
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654
Mailing Address - Country:US
Mailing Address - Phone:662-890-7660
Mailing Address - Fax:662-890-7661
Practice Address - Street 1:THE SMITH CLINIC FOR PHYSICAL THERAPY
Practice Address - Street 2:7037 HACKS CROSS ROAD
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-890-7660
Practice Address - Fax:662-890-7661
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3627225100000X
TN6079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ02908Medicare UPIN
MSP00063308Medicare ID - Type UnspecifiedRAILROAD MEDICARE