Provider Demographics
NPI:1508152984
Name:CLAXTON, STACEYANN MONIQUE (DPT)
Entity Type:Individual
Prefix:MS
First Name:STACEYANN
Middle Name:MONIQUE
Last Name:CLAXTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BROOKLYN AVE APT 4U
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2991
Mailing Address - Country:US
Mailing Address - Phone:516-984-3231
Mailing Address - Fax:516-414-1877
Practice Address - Street 1:110 BROOKLYN AVE APT 4U
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2991
Practice Address - Country:US
Practice Address - Phone:516-984-3231
Practice Address - Fax:516-414-1877
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030905-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist