Healthcare Provider Details

I. General information

NPI: 1396139721
Provider Name (Legal Business Name): STEPHANIE GUMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 EUREKA RD STE 103
ROSEVILLE CA
95661-3047
US

IV. Provider business mailing address

1528 EUREKA RD STE 103
ROSEVILLE CA
95661-3047
US

V. Phone/Fax

Practice location:
  • Phone: 916-772-5325
  • Fax: 916-771-6338
Mailing address:
  • Phone: 916-772-5325
  • Fax: 916-771-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number55039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: