Healthcare Provider Details

I. General information

NPI: 1528081007
Provider Name (Legal Business Name): STACIE LEE HAWORTH M.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 CRESTON PARK DR
JANESVILLE WI
53545-1126
US

IV. Provider business mailing address

4412 TOUCHSTONE DR
ONEIDA WI
54155-8662
US

V. Phone/Fax

Practice location:
  • Phone: 608-756-9440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number9823-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: