Provider Demographics
NPI:1538294772
Name:FLEETWOOD, STACEY LEE (MSPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:FLEETWOOD
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66102-1749
Mailing Address - Country:US
Mailing Address - Phone:913-287-8851
Mailing Address - Fax:
Practice Address - Street 1:4911 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1749
Practice Address - Country:US
Practice Address - Phone:913-287-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02852225100000X
MO2004009998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2004009998OtherSTATE LICENSE
KS11-02852OtherSTATE LICENSE