Provider Demographics
NPI:1760532717
Name:BERTSCH, STACY (LMP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BERTSCH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N NYDEN FARMS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-9705
Mailing Address - Country:US
Mailing Address - Phone:425-290-6024
Mailing Address - Fax:425-776-4357
Practice Address - Street 1:6603 220TH ST SW STE C-1
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2186
Practice Address - Country:US
Practice Address - Phone:425-776-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018581174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist