Provider Demographics
NPI:1689756603
Name:SCANLAN, STACEY L (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:SCANLAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 N BOGUS BASIN ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-344-0737
Mailing Address - Fax:208-344-0759
Practice Address - Street 1:2302 N BOGUS BASIN ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-344-0730
Practice Address - Fax:208-344-0759
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1355225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID102560035Medicaid
1578799094OtherTHRIVE PT AND PILATES GROUP NPI
1655192Medicare PIN