Provider Demographics
NPI:1205888104
Name:DOSS, STACIE (MPT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:DOSS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2454 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2548
Mailing Address - Country:US
Mailing Address - Phone:636-916-4625
Mailing Address - Fax:636-916-4628
Practice Address - Street 1:2454 W CLAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2548
Practice Address - Country:US
Practice Address - Phone:636-949-3926
Practice Address - Fax:636-949-3928
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005022714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00361867OtherRAILROAD MEDICARE
MO220531643Medicare PIN