Provider Demographics
NPI:1063468767
Name:SANDERS, STACY D (PT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:D
Other - Last Name:ECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:200
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:2090 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2522
Practice Address - Country:US
Practice Address - Phone:651-968-5801
Practice Address - Fax:651-968-5899
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73412251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650001460OtherMEDICARE
MN1063468767Medicaid
MNP00326353OtherRAILROAD MEDICARE