Provider Demographics
NPI:1124734090
Name:LEEST, STEPHANIE (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LEEST
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 SAM RITTENBERG BLVD APT 1004
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4882
Mailing Address - Country:US
Mailing Address - Phone:203-376-3163
Mailing Address - Fax:
Practice Address - Street 1:1916 SAM RITTENBERG BLVD APT 1004
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4882
Practice Address - Country:US
Practice Address - Phone:203-376-3163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA96259225700000X
TXMT135014225700000X
SC10606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty