Provider Demographics
NPI:1134451552
Name:DECRISTOFARO, STACY (DT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DECRISTOFARO
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1799 KINGS GATE LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-2906
Mailing Address - Country:US
Mailing Address - Phone:815-276-7786
Mailing Address - Fax:815-788-1321
Practice Address - Street 1:1799 KINGS GATE LN
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-2906
Practice Address - Country:US
Practice Address - Phone:815-276-7786
Practice Address - Fax:815-788-1321
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist