Provider Demographics
NPI:1417200973
Name:BROWN, STACEY ILYSE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ILYSE
Last Name:BROWN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ILYSE
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:890 LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-2360
Mailing Address - Country:US
Mailing Address - Phone:610-225-2451
Mailing Address - Fax:
Practice Address - Street 1:890 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-2360
Practice Address - Country:US
Practice Address - Phone:610-225-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA40QA01467900208100000X
PAPT022212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation