Provider Demographics
NPI:1699958058
Name:LAIBOW, STACEY (DPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LAIBOW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3655
Mailing Address - Country:US
Mailing Address - Phone:714-838-6999
Mailing Address - Fax:
Practice Address - Street 1:250 EL CAMINO REAL
Practice Address - Street 2:SUITE 100
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3655
Practice Address - Country:US
Practice Address - Phone:714-838-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT342362251N0400X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17811Medicare PIN