Basic Information
| Provider Information | |||||||||
| NPI: | 1154782811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | THELMA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1624 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037308105 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3681 LEAPHART RD STE A | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291693068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034546090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2016 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1560 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.