Provider Demographics
NPI:1619353406
Name:NWABUEZE, STACIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:NWABUEZE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:LA
Mailing Address - Zip Code:70748-6135
Mailing Address - Country:US
Mailing Address - Phone:225-634-3517
Mailing Address - Fax:225-634-5057
Practice Address - Street 1:3050 CHARLES DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748-6135
Practice Address - Country:US
Practice Address - Phone:225-634-3517
Practice Address - Fax:225-634-5057
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALRC-790225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner