Provider Demographics
NPI:1497867188
Name:LOFSTAD, STACEY LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:LOFSTAD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 LOCUST PL
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-3509
Mailing Address - Country:US
Mailing Address - Phone:631-608-1622
Mailing Address - Fax:
Practice Address - Street 1:14 LOCUST PL
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-3509
Practice Address - Country:US
Practice Address - Phone:631-608-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000077-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer