Healthcare Provider Details

I. General information

NPI: 1588821441
Provider Name (Legal Business Name): STACIE RENEE WALSH LAC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23023 38TH CT W
BRIER WA
98036-8262
US

IV. Provider business mailing address

23023 38TH CT W
BRIER WA
98036-8262
US

V. Phone/Fax

Practice location:
  • Phone: 541-806-0704
  • Fax:
Mailing address:
  • Phone: 541-806-0704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 60249633
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017665
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: