Provider Demographics
NPI:1083816243
Name:HATHCOCK, STACEY ALLEN (DPT)
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:ALLEN
Last Name:HATHCOCK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:274 EASTWOOD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-5933
Mailing Address - Country:US
Mailing Address - Phone:229-271-3760
Mailing Address - Fax:229-271-4612
Practice Address - Street 1:307 THIRD AVENUE
Practice Address - Street 2:CRISP REGIONAL THERAPIES
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-271-4612
Practice Address - Fax:229-271-4616
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA474753088AMedicaid