Provider Demographics
NPI:1932257110
Name:WOODWORTH, STACIE NICHOLE (ATC)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:NICHOLE
Last Name:WOODWORTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W CHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60151-9193
Mailing Address - Country:US
Mailing Address - Phone:630-707-7556
Mailing Address - Fax:
Practice Address - Street 1:2128 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3199
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL960014002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer