Provider Demographics
NPI:1295719847
Name:HILDEBRANDT, STACI A (DPT)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:A
Last Name:HILDEBRANDT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:A
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:STE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:702 BARRETT BLVD
Practice Address - Street 2:STE B
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4931
Practice Address - Country:US
Practice Address - Phone:270-631-4100
Practice Address - Fax:270-631-4101
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008671A225100000X
KY005465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200818510Medicaid
IN000000378690OtherBLUE CROSS BLUE SHIELD
IN000000558412OtherBLUE CROSS BLUE SHIELD
KY000000721633OtherBLUE CROSS BLUE SHIELD
IN000000378690OtherBLUE CROSS BLUE SHIELD
IN200818510Medicaid
IN255480BMedicare PIN