Provider Demographics
NPI:1447280250
Name:LIDDLE, STACY L (PT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:LIDDLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 BENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-6803
Mailing Address - Country:US
Mailing Address - Phone:512-420-9362
Mailing Address - Fax:
Practice Address - Street 1:911 W ANDERSON LN
Practice Address - Street 2:STE 117
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1501
Practice Address - Country:US
Practice Address - Phone:512-467-1100
Practice Address - Fax:512-467-1101
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11052112251X0800X
TXMT022197225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist