Provider Demographics
NPI:1821534538
Name:BRISCO, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BRISCO
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 1:13431 OLD MERIDIAN ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7101
Mailing Address - Country:US
Mailing Address - Phone:317-249-2616
Mailing Address - Fax:317-249-2618
Practice Address - Street 1:13431 OLD MERIDIAN ST
Practice Address - Street 2:SUITE 225
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7101
Practice Address - Country:US
Practice Address - Phone:317-249-2616
Practice Address - Fax:317-249-2618
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN310017421A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist