Provider Demographics
NPI:1578520276
Name:NEVILLE, STACEY A (PT)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:A
Last Name:NEVILLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:INGERSOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4415 WEST 36 1/2 STREET
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-927-9717
Mailing Address - Fax:952-927-7687
Practice Address - Street 1:4415 WEST 36 1/2 STREET
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:952-927-7687
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN457RINEOtherBCBS
HP43270OtherHEALTHPARTNERS
6404818OtherMEDICA