Provider Demographics
NPI:1134566144
Name:MALLOY, STACIE NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:NICOLE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:NICOLE
Other - Last Name:HUFFMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27110 JOINER DR
Mailing Address - Street 2:
Mailing Address - City:ST CATHARINE
Mailing Address - State:MO
Mailing Address - Zip Code:64628-8217
Mailing Address - Country:US
Mailing Address - Phone:660-258-8645
Mailing Address - Fax:
Practice Address - Street 1:122 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-1643
Practice Address - Country:US
Practice Address - Phone:660-258-7892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist