Provider Demographics
NPI:1437187069
Name:KNOWLES, STACEY L (MSPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:KNOWLES
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 W FOSTER AVE STE CW
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1087
Mailing Address - Country:US
Mailing Address - Phone:773-516-4146
Mailing Address - Fax:773-961-7922
Practice Address - Street 1:1830 W FOSTER AVE STE CW
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-516-4146
Practice Address - Fax:773-961-7922
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213898Medicare PIN