Provider Demographics
NPI:1073512257
Name:STACK-SIDES, CHRISTIE MARIE (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTIE
Middle Name:MARIE
Last Name:STACK-SIDES
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:MS
Other - First Name:CHRISTIE
Other - Middle Name:MARIE
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:3204 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4669
Mailing Address - Country:US
Mailing Address - Phone:410-224-4520
Mailing Address - Fax:
Practice Address - Street 1:6000 LAUREL BOWIE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4000
Practice Address - Country:US
Practice Address - Phone:301-860-0237
Practice Address - Fax:301-860-0076
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19776225100000X
DCPT2999225100000X
VA2305202173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3324525OtherAETNA HMO
MD604729-04OtherBCBS
7068079OtherAETNA PPO
MD604729-04OtherBCBS