Provider Demographics
NPI:1447208970
Name:MCKENZIE, STACEY L (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5111 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5214
Mailing Address - Country:US
Mailing Address - Phone:912-239-6140
Mailing Address - Fax:912-335-3539
Practice Address - Street 1:210 E. DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:912-644-5260
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
GAPT007947225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA549181518AMedicaid