Provider Demographics
NPI:1205875945
Name:DAVIS, STACY M (PT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 HOYT AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2317
Mailing Address - Country:US
Mailing Address - Phone:425-258-5330
Mailing Address - Fax:425-258-1592
Practice Address - Street 1:1188 106TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8614
Practice Address - Country:US
Practice Address - Phone:425-454-4864
Practice Address - Fax:425-646-3901
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2896225100000X
WAPT00007491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME334700099Medicaid
MEME0928Medicare ID - Type Unspecified
WAG8884493Medicare PIN