Basic Information
| Provider Information | |||||||||
| NPI: | 1770598203 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HEAD | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5213 S ALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036303600 | ||||||||
| FaxNumber: | 2036303600 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W BARBEE CHAPEL RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275178188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193852600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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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 | 225100000X | 7160 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P16070 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080007160CT01 | 01 | CT | BLUE CROSS BLUE SHEILD | OTHER | 004227999 | 05 | CT | MEDICAID |