Provider Demographics
NPI:1164774774
Name:NAKAYAMA, STACEY HALLARCES (DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:HALLARCES
Last Name:NAKAYAMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2909
Mailing Address - Country:US
Mailing Address - Phone:408-781-2511
Mailing Address - Fax:
Practice Address - Street 1:121 E 18TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3034
Practice Address - Country:US
Practice Address - Phone:213-792-2616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 39125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist