Provider Demographics
NPI:1033844428
Name:MARBLE, STACEY (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MARBLE
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 1:76 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-3639
Mailing Address - Country:US
Mailing Address - Phone:540-223-5865
Mailing Address - Fax:
Practice Address - Street 1:3514 N FOWLER AVE
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7210
Practice Address - Country:US
Practice Address - Phone:575-388-3127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT-2023-2380225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant