Provider Demographics
NPI:1013254002
Name:SUMMERS, STACY KIRSTEN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:KIRSTEN
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:KIRSTEN
Other - Last Name:HAGLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1136 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3577
Mailing Address - Country:US
Mailing Address - Phone:630-355-3300
Mailing Address - Fax:
Practice Address - Street 1:1136 N MILL ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3577
Practice Address - Country:US
Practice Address - Phone:630-355-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist