Provider Demographics
NPI:1053633081
Name:WHITFORD, STACEY A (PTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:WHITFORD
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 1:8 EICHEN CT
Mailing Address - Street 2:
Mailing Address - City:TICONDEROGA
Mailing Address - State:NY
Mailing Address - Zip Code:12883-3201
Mailing Address - Country:US
Mailing Address - Phone:518-837-1446
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0063417225200000X
NY006677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant