Basic Information
| Provider Information | |||||||||
| NPI: | 1578520276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEVILLE | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | INGERSOLL | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4415 WEST 36 1/2 STREET | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | 9529277687 | ||||||||
| Practice Location | |||||||||
| Address1: | 4415 WEST 36 1/2 STREET | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529279717 | ||||||||
| FaxNumber: | 9529277687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6566 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 457RINE | 01 | MN | BCBS | OTHER | HP43270 | 01 | HEALTHPARTNERS | OTHER | 6404818 | 01 | MEDICA | OTHER |