Healthcare Provider Details

I. General information

NPI: 1841471794
Provider Name (Legal Business Name): DEBORAH KAY STALCUP LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MERCHANT WAY SUIT 101
STATESBORO GA
30458-0868
US

IV. Provider business mailing address

144 RAILROAD AVE
ROCKY FORD GA
30455-7006
US

V. Phone/Fax

Practice location:
  • Phone: 912-489-4333
  • Fax:
Mailing address:
  • Phone: 912-687-2879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT002122
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: