Provider Demographics
NPI:1922474741
Name:STACY, JOSEANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOSEANE
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PERRAULT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3288
Mailing Address - Country:US
Mailing Address - Phone:601-941-8138
Mailing Address - Fax:
Practice Address - Street 1:24 PERRAULT RD
Practice Address - Street 2:SUITE 5
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-3288
Practice Address - Country:US
Practice Address - Phone:601-941-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10154225100000X
COPTL.0012960225100000X
MSPT 5002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist