Provider Demographics
NPI:1992375299
Name:BELLOWS, STACY L (PTA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:BELLOWS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2650 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54020
Mailing Address - Country:US
Mailing Address - Phone:715-294-1100
Mailing Address - Fax:
Practice Address - Street 1:2650 65TH AVE
Practice Address - Street 2:
Practice Address - City:OSCELOA
Practice Address - State:WI
Practice Address - Zip Code:54020
Practice Address - Country:US
Practice Address - Phone:715-294-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3180-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant