Provider Demographics
NPI:1437355831
Name:BROADHEAD, STACY (OTR)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BROADHEAD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 12TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-2506
Mailing Address - Country:US
Mailing Address - Phone:205-562-9658
Mailing Address - Fax:
Practice Address - Street 1:3024 12TH AVE E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-2506
Practice Address - Country:US
Practice Address - Phone:205-562-9658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1563251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health