Provider Demographics
NPI:1619413481
Name:GRODY, STACEY LYNNE (CTRS)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNNE
Last Name:GRODY
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:LYNNE
Other - Last Name:VANKLOMPENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1490 EAST BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-940-0040
Mailing Address - Fax:
Practice Address - Street 1:1490 EAST BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-940-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI45840225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist