Basic Information
| Provider Information | |||||||||
| NPI: | 1932257110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODWORTH | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W CHESTER DR | ||||||||
| Address2: | |||||||||
| City: | MAPLE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601519193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307077556 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2128 MIDLANDS CT | ||||||||
| Address2: | |||||||||
| City: | SYCAMORE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601783199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157580000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2007 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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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 | 2255A2300X | 96001400 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.