Provider Demographics
NPI:1144520669
Name:RUNKE, STACEY LYNN (MPT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:RUNKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 MARTELL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3117
Mailing Address - Country:US
Mailing Address - Phone:248-918-1927
Mailing Address - Fax:
Practice Address - Street 1:24611 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3035
Practice Address - Country:US
Practice Address - Phone:248-557-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1829893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist