Healthcare Provider Details

I. General information

NPI: 1275085458
Provider Name (Legal Business Name): MRS. STACY M GEESAMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SAINT LUKE DR
LITITZ PA
17543-2208
US

IV. Provider business mailing address

6 FOXRUN TER
LITITZ PA
17543-7905
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-6884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010189L
License Number StatePA

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: