Provider Demographics
NPI:1932384013
Name:CHURCHILL, STACEY JOYCE (MPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:JOYCE
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:JOYCE
Other - Last Name:WESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:1600 HUNT TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5184
Mailing Address - Country:US
Mailing Address - Phone:352-394-5549
Mailing Address - Fax:
Practice Address - Street 1:1600 HUNT TRACE BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5184
Practice Address - Country:US
Practice Address - Phone:352-394-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11349225100000X
FLPT26441225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212335Medicaid
NC068VVOtherBCBS OF NC
NC2504024Medicare UPIN