Provider Demographics
NPI:1801056064
Name:KETTLER, STACY JO (PT)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:JO
Last Name:KETTLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 HEATHER WOOD LN
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-3140
Mailing Address - Country:US
Mailing Address - Phone:636-931-2327
Mailing Address - Fax:
Practice Address - Street 1:1108 CLARKE ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2706
Practice Address - Country:US
Practice Address - Phone:636-586-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000152525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist