Provider Demographics
NPI:1114759412
Name:PURDY, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PURDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13377 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7810
Mailing Address - Country:US
Mailing Address - Phone:440-340-5558
Mailing Address - Fax:440-340-5575
Practice Address - Street 1:13377 SMITH RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-7810
Practice Address - Country:US
Practice Address - Phone:440-340-5558
Practice Address - Fax:440-340-5575
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004045175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist