| NPI | 1417200973 |
|---|---|
| Former Name | STACEY ILYSE ROTH |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: PA PT022212) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: PA 40QA01467900) |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2019-12-12 |