Basic Information
| Provider Information | |||||||||
| NPI: | 1265641260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWEENEY | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 SWAYNE DR | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281176049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077632126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 S MAIN ST STE 113 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281153228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043275911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | N | Other Service Providers | Health Educator | 225100000X | PT777 | WY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 171400000X | A-3631771 | Y |
ID Information
| ID | Type | State | Issuer | Description | 114429400 | 05 | WY | MEDICAID |