Healthcare Provider Details

I. General information

NPI: 1477865095
Provider Name (Legal Business Name): MS. STACIE DE L'ETOILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506 MEDFORD LAKE DR
RIVERVIEW FL
33578-0038
US

IV. Provider business mailing address

10506 MEDFORD LAKE DR
RIVERVIEW FL
33578-0038
US

V. Phone/Fax

Practice location:
  • Phone: 813-252-0180
  • Fax: 813-489-4082
Mailing address:
  • Phone: 813-252-0180
  • Fax: 813-489-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT25642
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT25642
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberPT25642
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: