Provider Demographics
NPI:1740455906
Name:BUCKLEY, STACEY LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16416 SAHLER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-2910
Mailing Address - Country:US
Mailing Address - Phone:402-660-8091
Mailing Address - Fax:
Practice Address - Street 1:13336 INDUSTRIAL RD STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1124
Practice Address - Country:US
Practice Address - Phone:402-330-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE559225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant