Provider Demographics
NPI:1023102100
Name:RAZZINO, STACIE JEAN (MSPT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:JEAN
Last Name:RAZZINO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:JEAN
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:1273 VESTAVIA CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2302
Mailing Address - Country:US
Mailing Address - Phone:321-757-5569
Mailing Address - Fax:
Practice Address - Street 1:1300 BEDFORD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1991
Practice Address - Country:US
Practice Address - Phone:321-242-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8852ZMedicare ID - Type Unspecified