Provider Demographics
NPI:1396108114
Name:RAY, STEPHAN
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:
Last Name:RAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-9343
Mailing Address - Country:US
Mailing Address - Phone:360-947-4890
Mailing Address - Fax:
Practice Address - Street 1:915 S HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-9343
Practice Address - Country:US
Practice Address - Phone:360-947-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60632974225700000X
OR21952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist