Provider Demographics
NPI:1740553585
Name:LANG, STACY GAYLE (PTA)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:GAYLE
Last Name:LANG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:GAYLE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:10457 SLATER AVE
Mailing Address - Street 2:203
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7710
Mailing Address - Country:US
Mailing Address - Phone:949-521-1912
Mailing Address - Fax:
Practice Address - Street 1:10457 SLATER AVE
Practice Address - Street 2:203
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7710
Practice Address - Country:US
Practice Address - Phone:949-521-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT926225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant