Provider Demographics
NPI:1033585773
Name:SPOON, STACEY BROOKE (PT, DPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:BROOKE
Last Name:SPOON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:BROOKE
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3666
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-3666
Mailing Address - Country:US
Mailing Address - Phone:361-782-7898
Mailing Address - Fax:361-782-6317
Practice Address - Street 1:1013 S WELLS ST
Practice Address - Street 2:
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957-4045
Practice Address - Country:US
Practice Address - Phone:361-782-7898
Practice Address - Fax:361-782-6317
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12646052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1264605Medicaid