Provider Demographics
NPI:1003428806
Name:BURRIS, STACI A (PTA)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:A
Last Name:BURRIS
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 1:1141 N NANCY ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-9554
Mailing Address - Country:US
Mailing Address - Phone:309-251-9707
Mailing Address - Fax:
Practice Address - Street 1:900 CENTENNIAL DR # 30
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-4928
Practice Address - Country:US
Practice Address - Phone:309-699-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005049225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant