Provider Demographics
NPI:1750548012
Name:BURTON, STACEY CARROLL (PLE)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:CARROLL
Last Name:BURTON
Suffix:
Gender:F
Credentials:PLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 HAIL KNOB RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3419
Mailing Address - Country:US
Mailing Address - Phone:606-219-0832
Mailing Address - Fax:
Practice Address - Street 1:801 HAIL KNOB RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3419
Practice Address - Country:US
Practice Address - Phone:606-219-0832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist