Basic Information
| Provider Information | |||||||||
| NPI: | 1295719847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILDEBRANDT | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURNS | ||||||||
| OtherFirstName: | STACI | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7300 E INDIANA ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477152794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 BARRETT BLVD | ||||||||
| Address2: | STE B | ||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424204931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706314100 | ||||||||
| FaxNumber: | 2706314101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05008671A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 005465 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200818510 | 05 | IN | MEDICAID | 000000378690 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 000000558412 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 000000721633 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER |