MEDICARE: MRS. STACEY CHILDS ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	25MT00134300	NJ

General Provider Information

NPI Number	:	1811155831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY CHILDS ATC

Provider Business Mailing Address
First Line	:	565 NUGENTOWN ROAD
Second Line	:	PINELANDS REGIONAL HIGH SCHOOL
City	:	LITTLE EGG HARBOR
State	:	NJ
Zip	:	08087
Country	:	US
Telephone Number	:	609-296-3106
Fax Number	:

Provider Business Practice Location Address
First Line	:	565 NUGENTOWN RD
Second Line	:	PINELANDS REGIONAL HIGH SCHOOL
City	:	LITTLE EGG HARBOR TWP
State	:	NJ
Zip	:	08087-3909
Country	:	US
Telephone Number	:	609-296-3106
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	10/12/2015

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