Provider Demographics
NPI:1265625594
Name:MINIO, STACEY ANN (PT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:MINIO
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 1:55 E RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:UPPER HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19053-1539
Mailing Address - Country:US
Mailing Address - Phone:215-208-0654
Mailing Address - Fax:215-734-2402
Practice Address - Street 1:55 E RIDGE CIR
Practice Address - Street 2:
Practice Address - City:UPPER HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:19053-1539
Practice Address - Country:US
Practice Address - Phone:215-208-0654
Practice Address - Fax:215-734-2402
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00913100225100000X
PAPT015604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1265625594Medicaid