Provider Demographics
NPI:1770598203
Name:HEAD, STACEY MARIE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:HEAD
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 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:203-630-3600
Mailing Address - Fax:203-630-3600
Practice Address - Street 1:801 W BARBEE CHAPEL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-8188
Practice Address - Country:US
Practice Address - Phone:919-385-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7160225100000X
NCP16070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080007160CT01OtherBLUE CROSS BLUE SHEILD
CT004227999Medicaid
CT650000755Medicare ID - Type Unspecified