1154552719 NPI number — STACEY L HAUGHT PT

Table of content: STACEY L HAUGHT PT (NPI 1154552719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154552719 NPI number — STACEY L HAUGHT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAUGHT
Provider First Name:
STACEY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUBAKER
Provider Other First Name:
STACEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154552719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4016 RAINTREE RD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23321-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-488-2864
Provider Business Mailing Address Fax Number:
757-488-4735

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4016 RAINTREE RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23321-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-488-2864
Provider Business Practice Location Address Fax Number:
757-488-4735
Provider Enumeration Date:
07/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X , with the licence number:  2305206037 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004979061 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".