Provider Demographics
NPI:1235735879
Name:CROUSER, STACY
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:CROUSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1460 CONGRESS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MOGADORE
Mailing Address - State:OH
Mailing Address - Zip Code:44260-1924
Mailing Address - Country:US
Mailing Address - Phone:330-807-2345
Mailing Address - Fax:
Practice Address - Street 1:1460 CONGRESS LAKE RD
Practice Address - Street 2:
Practice Address - City:MOGADORE
Practice Address - State:OH
Practice Address - Zip Code:44260-1924
Practice Address - Country:US
Practice Address - Phone:330-807-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker