Provider Demographics
NPI:1366796955
Name:GERUSO, STEPHANIE LAUREN (MS, ATC, CSCS, CES,)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAUREN
Last Name:GERUSO
Suffix:
Gender:F
Credentials:MS, ATC, CSCS, CES,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6057 WILLOMERE CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-3731
Mailing Address - Country:US
Mailing Address - Phone:919-819-6649
Mailing Address - Fax:
Practice Address - Street 1:211 OLD LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3428
Practice Address - Country:US
Practice Address - Phone:336-474-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-03
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC080102265246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other