Provider Demographics
NPI:1043406234
Name:SUMMEROUR, STACEY LYNNE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNNE
Last Name:SUMMEROUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 JOSEPH WALKER DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-6939
Mailing Address - Country:US
Mailing Address - Phone:803-936-0310
Mailing Address - Fax:
Practice Address - Street 1:100 JOSEPH WALKER DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6939
Practice Address - Country:US
Practice Address - Phone:803-936-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1894225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant