MEDICARE: STEPHANIE ROARK L.M.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA52089	FL

General Provider Information

NPI Number	:	1578881397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ROARK L.M.T.

Provider Business Mailing Address
First Line	:	5602 KENSINGTON LOOP
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-2045
Country	:	US
Telephone Number	:	239-405-3670
Fax Number	:

Provider Business Practice Location Address
First Line	:	6710 WINKLER RD STE 2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-7274
Country	:	US
Telephone Number	:	239-405-3670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2010
Last Update Date	:	05/05/2010

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