Provider Demographics
NPI:1063557262
Name:ECK, STACEY ANN (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:ECK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:ANN
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:5000 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241
Mailing Address - Country:US
Mailing Address - Phone:920-794-5376
Mailing Address - Fax:920-794-5472
Practice Address - Street 1:3821 DEWEY ST.
Practice Address - Street 2:
Practice Address - City:MANIOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-682-7585
Practice Address - Fax:920-686-3601
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10686024225100000X
WI10686-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36144900Medicaid