Provider Demographics
NPI:1194781542
Name:BECK, STACY (PT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:BECK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 SOUCHAK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8326
Mailing Address - Country:US
Mailing Address - Phone:928-855-5654
Mailing Address - Fax:
Practice Address - Street 1:297 S LAKE HAVASU AVE #102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-453-0501
Practice Address - Fax:928-453-0502
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ71814Medicare ID - Type Unspecified