Provider Demographics
NPI:1285077941
Name:FREDRICKSON, STACY A (PT, DPT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:A
Other - Last Name:ORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-576-6200
Mailing Address - Fax:
Practice Address - Street 1:10787 RANDOLPH ST STE 220
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46307-7615
Practice Address - Country:US
Practice Address - Phone:219-333-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010467A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist