Provider Demographics
NPI:1205990439
Name:STELLY, PRESTON JOSEPH JR (PT, OT)
Entity type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:JOSEPH
Last Name:STELLY
Suffix:JR
Gender:M
Credentials:PT, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5050
Mailing Address - Country:US
Mailing Address - Phone:337-533-8410
Mailing Address - Fax:337-533-8411
Practice Address - Street 1:522 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5050
Practice Address - Country:US
Practice Address - Phone:337-533-8410
Practice Address - Fax:337-533-8411
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1056738225X00000X
LAPT05159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A520DC19Medicare PIN