Provider Demographics
NPI:1235459330
Name:GROSSMAN, STACEY ALLISON (MSPT)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ALLISON
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 W. CHEYENNE AVE
Mailing Address - Street 2:PARAGON HEALTH CARE
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129
Mailing Address - Country:US
Mailing Address - Phone:702-214-6665
Mailing Address - Fax:
Practice Address - Street 1:7324 W. CHEYENNE AVE
Practice Address - Street 2:PARAGON HEALTH CARE
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-0000
Practice Address - Country:US
Practice Address - Phone:702-214-6665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist