Provider Demographics
NPI:1811155831
Name:CHILDS, STACEY (ATC)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:CHILDS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 NUGENTOWN ROAD
Mailing Address - Street 2:PINELANDS REGIONAL HIGH SCHOOL
Mailing Address - City:LITTLE EGG HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08087
Mailing Address - Country:US
Mailing Address - Phone:609-296-3106
Mailing Address - Fax:
Practice Address - Street 1:565 NUGENTOWN RD
Practice Address - Street 2:PINELANDS REGIONAL HIGH SCHOOL
Practice Address - City:LITTLE EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08087-3909
Practice Address - Country:US
Practice Address - Phone:609-296-3106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001343002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer