Provider Demographics
NPI:1669879078
Name:WARREN, STACY (DPT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5474 SHAWNEE CIR APT. 30
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-3377
Mailing Address - Country:US
Mailing Address - Phone:740-671-8458
Mailing Address - Fax:304-201-5123
Practice Address - Street 1:179 STATION PL
Practice Address - Street 2:SUITE 100
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-6578
Practice Address - Country:US
Practice Address - Phone:304-760-6300
Practice Address - Fax:304-201-5123
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT 0034202251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics