Provider Demographics
NPI:1508528050
Name:ELMER, STACI (PTA)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:ELMER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:BARADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2240 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1239
Mailing Address - Country:US
Mailing Address - Phone:304-525-4445
Mailing Address - Fax:304-529-7449
Practice Address - Street 1:907 OAK ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1422
Practice Address - Country:US
Practice Address - Phone:304-525-4460
Practice Address - Fax:304-529-7449
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001901225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant