Provider Demographics
NPI:1164857629
Name:HARDIN, STACEY (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HARDIN
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 BABCOCK ST
Mailing Address - Street 2:ATHLETIC TRAINING
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3601
Mailing Address - Country:US
Mailing Address - Phone:707-386-7112
Mailing Address - Fax:
Practice Address - Street 1:285 BABCOCK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1003
Practice Address - Country:US
Practice Address - Phone:707-386-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20684225100000X
MA24872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist