1801906375 NPI number — STACEY J LADD PT

Table of content: STACEY J LADD PT (NPI 1801906375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801906375 NPI number — STACEY J LADD PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADD
Provider First Name:
STACEY
Provider Middle Name:
J
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:
OLSEN
Provider Other First Name:
STACEY
Provider Other Middle Name:
J
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:
1801906375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776
Provider Second Line Business Mailing Address:
184 ROUTE 7 SOUTH
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05468-0776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-893-7427
Provider Business Mailing Address Fax Number:
802-893-7429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
184 ROUTE 7 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05468-0776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-893-7427
Provider Business Practice Location Address Fax Number:
802-893-7429
Provider Enumeration Date:
08/30/2006

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: 225100000X , with the licence number:  0400002594 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4124858 . This is a "MVP HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00028864 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1006935 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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