Provider Demographics
NPI:1417006214
Name:PICKERT, STACEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:PICKERT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15326 W 128TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-5888
Mailing Address - Country:US
Mailing Address - Phone:913-235-9109
Mailing Address - Fax:
Practice Address - Street 1:23351 PRAIRIE STAR PKWY STE A275
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66227-7302
Practice Address - Country:US
Practice Address - Phone:913-351-3005
Practice Address - Fax:913-351-3009
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-001072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer