Provider Demographics
NPI:1962485821
Name:RICHARDS, STACEY ELAINE (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ELAINE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ELAINE
Other - Last Name:BETTCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:1005 N EVERGREEN RD
Practice Address - Street 2:SUITE 010
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1485
Practice Address - Country:US
Practice Address - Phone:509-926-5367
Practice Address - Fax:509-928-5508
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1962485821Medicaid
WA8367534Medicaid
WAAB38828Medicare PIN