Provider Demographics
NPI:1740395151
Name:GOLDBERG, STACY HOPE (MSPT)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:HOPE
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 CARLYON AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3501
Mailing Address - Country:US
Mailing Address - Phone:206-788-7446
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:BOX 356490
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6490
Practice Address - Country:US
Practice Address - Phone:206-598-4830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist