Provider Demographics
NPI:1073514469
Name:MATTHEWS, STACEY (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MATTHEWS
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 1:3737 BRITTON RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:MI
Mailing Address - Zip Code:48872-9716
Mailing Address - Country:US
Mailing Address - Phone:517-625-0772
Mailing Address - Fax:517-625-0778
Practice Address - Street 1:3737 BRITTON RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:MI
Practice Address - Zip Code:48872-9716
Practice Address - Country:US
Practice Address - Phone:517-625-0772
Practice Address - Fax:517-625-0778
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISM010543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP26307FOtherBLUE CARE NETWORK MI
MI0G80003OtherBCBS OF MICHIGAN
MI6400072OtherPHP
MI990503OtherHEALTHPLUS
MI0N68780002Medicare PIN