Provider Demographics
NPI:1821309006
Name:FUNK, STACEY MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:FUNK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 ARTESIA BLVD
Mailing Address - Street 2:STE 207
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3413
Mailing Address - Country:US
Mailing Address - Phone:310-371-4774
Mailing Address - Fax:310-371-3453
Practice Address - Street 1:31228 PALOS VERDES DR W
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-5361
Practice Address - Country:US
Practice Address - Phone:310-544-7325
Practice Address - Fax:310-544-2625
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296872251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29687OtherPHYSICAL THERAPY LICENSE
CADI970ZMedicare PIN