Basic Information
| Provider Information | |||||||||
| NPI: | 1174576128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSCINSKI | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12727 KIMBERLEY LN | ||||||||
| Address2: | STE 103 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770244047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133659338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4009 BELLAIRE BLVD | ||||||||
| Address2: | SUITE M | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770251168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136690042 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 12/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251N0400X | 1144210 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1144210 | 01 | TX | LICENSE | OTHER | 1046077 | 01 | TX | BLUE LINK NUMBER | OTHER |