Provider Demographics
NPI:1902028483
Name:SMITH, STACY (PT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:BOWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:NORTHEAST PREMIER PHYSICAL MEDICINE, LLC
Mailing Address - Street 2:PO BOX 1153
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06083-1153
Mailing Address - Country:US
Mailing Address - Phone:860-232-1576
Mailing Address - Fax:860-432-8669
Practice Address - Street 1:NORTHEAST PREMIER PHYSICAL MEDICINE, LLC
Practice Address - Street 2:151 NEW PARK AVENUE, STE 4
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-232-1576
Practice Address - Fax:860-432-8669
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 007820225100000X
CT007820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist