Provider Demographics
NPI:1992467690
Name:WEBER, STACY MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:WEBER
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 1:1201 E 11 MILE RD APT 110
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2095
Mailing Address - Country:US
Mailing Address - Phone:219-616-1745
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501020265225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist