Provider Demographics
NPI:1013359611
Name:PERICLOS, STACIE (PT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:PERICLOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13801 E BENSON HWY
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-9074
Mailing Address - Country:US
Mailing Address - Phone:520-879-2052
Mailing Address - Fax:
Practice Address - Street 1:13801 E BENSON HWY
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-9074
Practice Address - Country:US
Practice Address - Phone:520-879-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29572251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1952438368Medicaid