Provider Demographics
NPI:1750468880
Name:DALE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 SE COUNTY ROAD Y
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-8350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 E YOUNG AVE STE B12
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-9609
Practice Address - Country:US
Practice Address - Phone:660-747-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO105568OtherLICENSE#