Provider Demographics
NPI:1295335693
Name:STAILEY, RONALD DEWEY (PTA)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:DEWEY
Last Name:STAILEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17094 AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3400
Mailing Address - Country:US
Mailing Address - Phone:225-677-8400
Mailing Address - Fax:225-677-8484
Practice Address - Street 1:17094 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3400
Practice Address - Country:US
Practice Address - Phone:225-677-8400
Practice Address - Fax:225-677-8484
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist