Basic Information
| Provider Information | |||||||||
| NPI: | 1932441862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOLAN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 HOSPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | WHITEFISH | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599377849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068633500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1343 US HIGHWAY 93 N | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599179503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062972438 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 03/18/2013 | ||||||||
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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 | 440 | MT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 440 | 01 | MT | PTP-PT-LIC | OTHER |