Provider Demographics
NPI:1023129129
Name:CALLOW, STACY RANAE (DPT, OCS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:RANAE
Last Name:CALLOW
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:RANAE
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1212 GARFIELD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3247
Mailing Address - Country:US
Mailing Address - Phone:304-865-6778
Mailing Address - Fax:304-865-7400
Practice Address - Street 1:63 HOSPITALITY LN
Practice Address - Street 2:SUITE 1
Practice Address - City:MINERAL WELLS
Practice Address - State:WV
Practice Address - Zip Code:26150-6704
Practice Address - Country:US
Practice Address - Phone:304-489-8100
Practice Address - Fax:304-489-8191
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007455Medicaid
OH2702623Medicaid
P00352738OtherRAILROAD MEDICARE
P00352738OtherRAILROAD MEDICARE