Provider Demographics
NPI:1285912584
Name:DESJARDINS, STACY A (NMT, CMT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:DESJARDINS
Suffix:
Gender:F
Credentials:NMT, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MONTGOMERY DR
Mailing Address - Street 2:SUITE L-4
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-953-2811
Mailing Address - Fax:
Practice Address - Street 1:4000 MONTGOMERY DR
Practice Address - Street 2:SUITE L-4
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-5281
Practice Address - Country:US
Practice Address - Phone:707-953-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist