Basic Information
| Provider Information | |||||||||
| NPI: | 1386953099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 487 | ||||||||
| Address2: | 1333 SPRING ST. | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314874638 | ||||||||
| FaxNumber: | 2314874615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 SPRING ST. | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314874638 | ||||||||
| FaxNumber: | 2314874615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502000603 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 404773166 | 05 | MI | MEDICAID |