Provider Demographics
NPI:1912930462
Name:DE YOUNG, STACEY MICHELLE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:DE YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-0369
Mailing Address - Country:US
Mailing Address - Phone:864-201-4301
Mailing Address - Fax:678-840-2112
Practice Address - Street 1:207 HUDDERSFIELD DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3703
Practice Address - Country:US
Practice Address - Phone:864-987-0365
Practice Address - Fax:678-840-2112
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3068225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist