Provider Demographics
NPI:1104206093
Name:ROEDER, STACIE SUZANNE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:SUZANNE
Last Name:ROEDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:SUZANNE
Other - Last Name:TOON-ROEDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:35324 HIGHWAY 41
Mailing Address - Street 2:SUITE D
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-9285
Mailing Address - Country:US
Mailing Address - Phone:559-641-5445
Mailing Address - Fax:559-641-5449
Practice Address - Street 1:35324 HIGHWAY 41
Practice Address - Street 2:SUITE D
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-9285
Practice Address - Country:US
Practice Address - Phone:559-641-5445
Practice Address - Fax:559-641-5449
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist