Provider Demographics
NPI:1962513655
Name:DAVIS, STACEY MARIE (PTA, CLT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1576 MERRITT BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222-2114
Mailing Address - Country:US
Mailing Address - Phone:410-650-2145
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 7
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2114
Practice Address - Country:US
Practice Address - Phone:410-650-2145
Practice Address - Fax:410-282-5955
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3045225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant