Provider Demographics
NPI:1902048069
Name:LICHT, STACY LEIGH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEIGH
Last Name:LICHT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LEBANON VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-8477
Mailing Address - Country:US
Mailing Address - Phone:423-310-0555
Mailing Address - Fax:423-479-4421
Practice Address - Street 1:500 LEBANON VALLEY RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-8477
Practice Address - Country:US
Practice Address - Phone:423-310-0555
Practice Address - Fax:423-479-4421
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT8088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist