Provider Demographics
NPI:1003846965
Name:TINGLEY, STACY R
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:TINGLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:MOWEAQUA
Mailing Address - State:IL
Mailing Address - Zip Code:62550-1019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1261 KEY WEST DR
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61103-8880
Practice Address - Country:US
Practice Address - Phone:217-412-6286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008804225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist