Provider Demographics
NPI:1578251138
Name:CHEN, STACEY (ATC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CHEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14116 FOREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4824
Mailing Address - Country:US
Mailing Address - Phone:240-994-7149
Mailing Address - Fax:
Practice Address - Street 1:13537 BARRETT PARKWAY DR STE 105
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-5896
Practice Address - Country:US
Practice Address - Phone:815-274-7026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190325282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer