Provider Demographics
NPI:1841288222
Name:THETFORD, STACY L (PT)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:L
Last Name:THETFORD
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:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:ROGUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97537-1467
Mailing Address - Country:US
Mailing Address - Phone:541-582-2323
Mailing Address - Fax:541-582-2419
Practice Address - Street 1:230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9416
Practice Address - Country:US
Practice Address - Phone:541-582-2323
Practice Address - Fax:541-582-2419
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR3171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR650019610Medicare ID - Type UnspecifiedRAILROAD
ORR104323Medicare ID - Type Unspecified