Provider Demographics
NPI:1548511777
Name:HART, STACEY L (PTA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:HART
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24216 WITTE RD SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6827
Mailing Address - Country:US
Mailing Address - Phone:425-433-3500
Mailing Address - Fax:
Practice Address - Street 1:24216 WITTE RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6827
Practice Address - Country:US
Practice Address - Phone:425-433-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60042716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist