Healthcare Provider Details

I. General information

NPI: 1376543884
Provider Name (Legal Business Name): STACI GAYE ELLIS MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACI GAYE GUFFEY MSPT

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7308 BRIDGEPORT WAY W STE 103
LAKEWOOD WA
98499-8000
US

IV. Provider business mailing address

3209 S 23RD ST
TACOMA WA
98405-1602
US

V. Phone/Fax

Practice location:
  • Phone: 253-582-8500
  • Fax: 253-582-8160
Mailing address:
  • Phone: 253-459-6999
  • Fax: 253-459-6980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT7361
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: