=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700164324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE L MANEVITCH LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2011
-----------------------------------------------------
Last Update Date | 07/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9514 AEGEAN DR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-212-1894
-----------------------------------------------------
Fax | 561-477-8053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9514 AEGEAN DR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-212-1894
-----------------------------------------------------
Fax | 561-477-8053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA30313
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 1431M
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------