Provider Demographics
NPI:1104001452
Name:ELLINGSON, STACEY A (PT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:ELLINGSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:SCHWENK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0480
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:12900 NE 180TH ST STE 110
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-5773
Practice Address - Country:US
Practice Address - Phone:425-483-4270
Practice Address - Fax:425-483-4268
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist