Provider Demographics
NPI:1902480072
Name:STEWART, KYRA (PTA)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37295 MARIETTA ST
Mailing Address - Street 2:
Mailing Address - City:SARDIS
Mailing Address - State:OH
Mailing Address - Zip Code:43946-8718
Mailing Address - Country:US
Mailing Address - Phone:304-815-5715
Mailing Address - Fax:
Practice Address - Street 1:225 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1572
Practice Address - Country:US
Practice Address - Phone:304-455-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA002654225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty