Provider Demographics
NPI:1528819760
Name:STACY, MAGEN ADELINE (PT, DPT, OCS)
Entity type:Individual
Prefix:DR
First Name:MAGEN
Middle Name:ADELINE
Last Name:STACY
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:DR
Other - First Name:MAGEN
Other - Middle Name:ADELINE
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, OCS
Mailing Address - Street 1:4601 ROCKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-2166
Mailing Address - Country:US
Mailing Address - Phone:540-267-5713
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist