Provider Demographics
NPI:1285281113
Name:STACY, BROOKE DUNCAN
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:DUNCAN
Last Name:STACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:DUNCAN
Other - Last Name:BARBOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3615 NEWBURG RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3368
Mailing Address - Country:US
Mailing Address - Phone:502-909-0772
Mailing Address - Fax:
Practice Address - Street 1:3615 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3368
Practice Address - Country:US
Practice Address - Phone:502-909-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY108328225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist