MEDICARE: STACIE DESHANNON COOPER LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT106974	TX

General Provider Information

NPI Number	:	1720832009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE DESHANNON COOPER LMT

Provider Business Mailing Address
First Line	:	10169 MANZANILLA AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-1267
Country	:	US
Telephone Number	:	469-992-4246
Fax Number	:

Provider Business Practice Location Address
First Line	:	10169 MANZANILLA AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-1267
Country	:	US
Telephone Number	:	469-992-4246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2024
Last Update Date	:	04/15/2024

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Directions to “ STACIE DESHANNON COOPER LMT” Practice Location

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