Provider Demographics
NPI:1437341302
Name:MERTUS, STACEY ANN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:MERTUS
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 1:4655 RUFFNER ST
Mailing Address - Street 2:SUITE #270
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111
Mailing Address - Country:US
Mailing Address - Phone:800-787-6787
Mailing Address - Fax:800-787-6762
Practice Address - Street 1:4655 RUFFNER ST
Practice Address - Street 2:SUITE #270
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:800-787-6787
Practice Address - Fax:800-787-6762
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT5417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist