1821514712 NPI number — STACEY ROBERTS PHYSICAL THERAPIST

Table of content: STACEY ROBERTS PHYSICAL THERAPIST (NPI 1821514712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821514712 NPI number — STACEY ROBERTS PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
STACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821514712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6650 W STATE ST # 233
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53213-2827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-522-6153
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13825 W BURLEIGH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-3058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-754-3450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2017

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:  3946-24 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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