Provider Demographics
NPI:1922320480
Name:GRESHAM, STACEY (DPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GRESHAM
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 1:6683 CABIN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-9221
Mailing Address - Country:US
Mailing Address - Phone:719-301-0305
Mailing Address - Fax:
Practice Address - Street 1:6683 CABIN CREEK DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-9221
Practice Address - Country:US
Practice Address - Phone:719-301-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5774225100000X
COPTL.0014650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTH5774OtherSTATE LICENSE
AL51103926OtherBLUE CROSS BLUE SHIELD PTAN