Provider Demographics
NPI:1376737478
Name:MOENTER, STACEY L
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:MOENTER
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 1:4160 LITTLE YORK RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5800
Mailing Address - Country:US
Mailing Address - Phone:937-415-9100
Mailing Address - Fax:937-415-9191
Practice Address - Street 1:4160 LITTLE YORK RD
Practice Address - Street 2:SUITE 10
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5800
Practice Address - Country:US
Practice Address - Phone:937-415-9100
Practice Address - Fax:937-415-9191
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4226371Medicare PIN
OH4226372Medicare PIN