Provider Demographics
NPI:1023205671
Name:NEWSOM, STACEE (PT)
Entity Type:Individual
Prefix:
First Name:STACEE
Middle Name:
Last Name:NEWSOM
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 1:1302 NW PERSIMMON DR
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-8628
Mailing Address - Country:US
Mailing Address - Phone:816-726-7337
Mailing Address - Fax:816-847-0218
Practice Address - Street 1:640 NW JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-8278
Practice Address - Country:US
Practice Address - Phone:816-726-7337
Practice Address - Fax:816-847-0218
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002021172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist