Healthcare Provider Details

I. General information

NPI: 1578251138
Provider Name (Legal Business Name): STACEY CHEN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13537 BARRETT PARKWAY DR STE 105
BALLWIN MO
63021-5896
US

IV. Provider business mailing address

14116 FOREST RIDGE DR
NORTH POTOMAC MD
20878-4824
US

V. Phone/Fax

Practice location:
  • Phone: 815-274-7026
  • Fax:
Mailing address:
  • Phone: 240-994-7149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2019032528
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: