Healthcare Provider Details

I. General information

NPI: 1598995425
Provider Name (Legal Business Name): STACEY DYER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 PUTNAM PIKE UNIT 4
CHEPACHET RI
02814-1403
US

IV. Provider business mailing address

712 PUTNAM PIKE UNIT 4
CHEPACHET RI
02814-1403
US

V. Phone/Fax

Practice location:
  • Phone: 401-568-2200
  • Fax: 401-568-2206
Mailing address:
  • Phone: 401-568-2200
  • Fax: 401-568-2206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT01270
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: