Healthcare Provider Details

I. General information

NPI: 1336079268
Provider Name (Legal Business Name): STACIE LENEE WAY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 16TH ST
BEDFORD IN
47421-3823
US

IV. Provider business mailing address

804 16TH ST
BEDFORD IN
47421-3823
US

V. Phone/Fax

Practice location:
  • Phone: 812-583-7310
  • Fax: 762-214-9268
Mailing address:
  • Phone: 812-583-7310
  • Fax: 762-214-9268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT22608888
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: