Provider Demographics
NPI:1861824468
Name:THOMPSON, STACIE (PT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:THOMPSON
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 1:2122 TROY RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2540
Mailing Address - Country:US
Mailing Address - Phone:618-800-4620
Mailing Address - Fax:618-200-4621
Practice Address - Street 1:2122 TROY RD STE 120
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2540
Practice Address - Country:US
Practice Address - Phone:618-800-4620
Practice Address - Fax:618-200-4621
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist