Basic Information
| Provider Information | |||||||||
| NPI: | 1417200973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | ILYSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROTH | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | ILYSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 890 LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | DEVON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102252451 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 890 LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | DEVON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102252451 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 40QA01467900 | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | PT022212 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.