Provider Demographics
NPI:1619533510
Name:COLE, STACEY DANIELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DANIELLE
Last Name:COLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-2503
Mailing Address - Country:US
Mailing Address - Phone:205-994-5161
Mailing Address - Fax:
Practice Address - Street 1:183 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:TRUSSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35173-1496
Practice Address - Country:US
Practice Address - Phone:205-994-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH11680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL11680OtherPT
AL7601OtherPTA