Provider Demographics
NPI:1376543884
Name:ELLIS, STACI GAYE (MSPT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:GAYE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:GAYE
Other - Last Name:GUFFEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSPT
Mailing Address - Street 1:3209 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1602
Mailing Address - Country:US
Mailing Address - Phone:253-459-6999
Mailing Address - Fax:253-459-6980
Practice Address - Street 1:7308 BRIDGEPORT WAY W STE 103
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8000
Practice Address - Country:US
Practice Address - Phone:253-582-8500
Practice Address - Fax:253-582-8160
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT7361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00007361OtherPT LICENSE