Provider Demographics
NPI:1508196478
Name:WIESE-BROWN, STACY MICHELLE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MICHELLE
Last Name:WIESE-BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CONNORS WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:45203
Mailing Address - Country:US
Mailing Address - Phone:606-875-5942
Mailing Address - Fax:
Practice Address - Street 1:28 CONNORS WAY
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:45203
Practice Address - Country:US
Practice Address - Phone:606-875-5942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist