Provider Demographics
NPI:1700120342
Name:RAAFLAUB, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RAAFLAUB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8274 E SAN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH RANGE
Mailing Address - State:WI
Mailing Address - Zip Code:54874-8621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8274 E SAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH RANGE
Practice Address - State:WI
Practice Address - Zip Code:54874-8621
Practice Address - Country:US
Practice Address - Phone:715-398-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1096-19225200000X
MNA851225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant