Provider Demographics
NPI:1376941377
Name:STACY, COREY V (AT, ATC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:V
Last Name:STACY
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7397 JOSHUA TRCE
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7002
Mailing Address - Country:US
Mailing Address - Phone:740-816-8420
Mailing Address - Fax:
Practice Address - Street 1:7397 JOSHUA TRCE
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7002
Practice Address - Country:US
Practice Address - Phone:740-816-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0045312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer