Provider Demographics
NPI:1821241100
Name:HENDRICKS, STACEY (DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 MIAMI RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227
Mailing Address - Country:US
Mailing Address - Phone:513-760-5511
Mailing Address - Fax:
Practice Address - Street 1:3908 MIAMI RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227
Practice Address - Country:US
Practice Address - Phone:513-760-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013647225100000X
NC11881225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist