Healthcare Provider Details

I. General information

NPI: 1588968200
Provider Name (Legal Business Name): DIANA STEPHENS MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA CRAFT

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 WINDWARD WAY SUITE 101
KALISPELL MT
59901-3133
US

IV. Provider business mailing address

245 WINDWARD WAY SUITE 101
KALISPELL MT
59901-3133
US

V. Phone/Fax

Practice location:
  • Phone: 406-756-8488
  • Fax: 406-257-4663
Mailing address:
  • Phone: 406-756-8488
  • Fax: 406-257-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4400476
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: