Provider Demographics
NPI:1841884558
Name:BREWER, STACY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:BREWER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12655 MCKINSTRY RD
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-3403
Mailing Address - Country:US
Mailing Address - Phone:636-288-8718
Mailing Address - Fax:
Practice Address - Street 1:11278 SCHUETZ RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4957
Practice Address - Country:US
Practice Address - Phone:314-991-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015022475208100000X
MO2015024275225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation