Provider Demographics
NPI:1164660593
Name:LYNCH, STACEY RENEE (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:RENEE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:600 OAKMONT LN
Mailing Address - Street 2:STE 600C
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:3734 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1800
Practice Address - Country:US
Practice Address - Phone:314-351-7172
Practice Address - Fax:314-351-6885
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009003505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO150900010Medicare PIN
IL532400004Medicare PIN
MO151100010Medicare PIN