Provider Demographics
NPI:1558505354
Name:MARGUERITE, STACEY ANNE (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:MARGUERITE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 PARK VIEW LN
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8968
Mailing Address - Country:US
Mailing Address - Phone:847-421-1076
Mailing Address - Fax:
Practice Address - Street 1:3330 OLD GLENVIEW RD
Practice Address - Street 2:SUITE 9
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2963
Practice Address - Country:US
Practice Address - Phone:847-421-1076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist