Provider Demographics
NPI:1073682803
Name:STACEY, RACHEL (PT)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:STACEY
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 1:611 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-2347
Mailing Address - Country:US
Mailing Address - Phone:618-942-4567
Mailing Address - Fax:
Practice Address - Street 1:3308 LOGAN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3759
Practice Address - Country:US
Practice Address - Phone:618-993-4024
Practice Address - Fax:618-993-1570
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700142662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16413Medicare ID - Type Unspecified