Provider Demographics
NPI:1275119539
Name:LONSER, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LONSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 AUTO CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2779
Mailing Address - Country:US
Mailing Address - Phone:313-982-8266
Mailing Address - Fax:
Practice Address - Street 1:5500 AUTO CLUB DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2779
Practice Address - Country:US
Practice Address - Phone:313-982-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000038225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant