Healthcare Provider Details

I. General information

NPI: 1376550210
Provider Name (Legal Business Name): STEPHANIE MARIE BURCH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 MILEGROUND RD APT H
MORGANTOWN WV
26505-3785
US

IV. Provider business mailing address

29 PLANTATION DR
MORGANTOWN WV
26508-2642
US

V. Phone/Fax

Practice location:
  • Phone: 304-216-7664
  • Fax:
Mailing address:
  • Phone: 304-216-7664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2004-1472
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: