Provider Demographics
NPI:1063758019
Name:GOODALE, STACEY S (PT)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:S
Last Name:GOODALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:KAY
Other - Last Name:SHEPPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2970 UNIVERSITY PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2401
Mailing Address - Country:US
Mailing Address - Phone:941-360-1988
Mailing Address - Fax:941-360-1998
Practice Address - Street 1:2970 UNIVERSITY PKWY STE 105
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2401
Practice Address - Country:US
Practice Address - Phone:941-360-1988
Practice Address - Fax:941-360-1998
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0F56OtherFL BC/BS
FLY0F56OtherFL BC/BS