Provider Demographics
NPI:1194258442
Name:WEST, STACY KATHLENA (AT, ATC)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:KATHLENA
Last Name:WEST
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:KATHLENA
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3106 REID RD
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8813
Mailing Address - Country:US
Mailing Address - Phone:810-845-0005
Mailing Address - Fax:
Practice Address - Street 1:3106 REID RD
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-8813
Practice Address - Country:US
Practice Address - Phone:810-845-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL5343152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer