Provider Demographics
NPI:1205946860
Name:STALEY, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:STALEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4047 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-6772
Mailing Address - Country:US
Mailing Address - Phone:407-957-0370
Mailing Address - Fax:
Practice Address - Street 1:4047 13TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769
Practice Address - Country:US
Practice Address - Phone:407-957-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007725OtherLICENSE #
FLPT34506OtherLICENSE #