Provider Demographics
NPI:1760579387
Name:VAN PELT, STACIE D
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:D
Last Name:VAN PELT
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 1:2835 N NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467-8096
Mailing Address - Country:US
Mailing Address - Phone:402-362-8636
Mailing Address - Fax:308-697-4179
Practice Address - Street 1:2835 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467-8096
Practice Address - Country:US
Practice Address - Phone:402-362-8636
Practice Address - Fax:308-697-4179
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE650018006OtherRR MEDICARE
NE36518OtherBCBS
NE272277OtherMEDICARE ID-PHYSICAL THERAPY