Provider Demographics
NPI:1508104936
Name:STACY, RACHAEL M (CTRS)
Entity Type:Individual
Prefix:MRS
First Name:RACHAEL
Middle Name:M
Last Name:STACY
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11339 56TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-9158
Mailing Address - Country:US
Mailing Address - Phone:209-224-1054
Mailing Address - Fax:855-207-3270
Practice Address - Street 1:11339 56TH AVE
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9158
Practice Address - Country:US
Practice Address - Phone:209-224-1054
Practice Address - Fax:855-207-3270
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist