Basic Information
| Provider Information | |||||||||
| NPI: | 1912279092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | ATC, PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 193 POOR VALLEY CREEK RD | ||||||||
| Address2: | |||||||||
| City: | ROGERSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378577319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232731011 | ||||||||
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| Practice Location | |||||||||
| Address1: | C&A PLAZA CALIFORNIA STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028911118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2079 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.