Provider Demographics
NPI:1982743688
Name:GORMAN, STACEY M (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:GORMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:225 N BENTON DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1575
Mailing Address - Country:US
Mailing Address - Phone:320-252-2225
Mailing Address - Fax:320-252-2159
Practice Address - Street 1:225 N BENTON DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1575
Practice Address - Country:US
Practice Address - Phone:320-252-2225
Practice Address - Fax:320-252-2159
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN7051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN510L2GOOtherBLUE CROSS & BLUE SHIELD