Provider Demographics
NPI:1386309995
Name:KENDALL, STEPHANIE J (LMT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:J
Last Name:KENDALL
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 1:24308 BROWNSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-7815
Mailing Address - Country:US
Mailing Address - Phone:850-356-9420
Mailing Address - Fax:
Practice Address - Street 1:55490 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-8304
Practice Address - Country:US
Practice Address - Phone:850-356-9420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501012082225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty