Provider Demographics
NPI:1528429941
Name:WILLIAMS, STACY (CMT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7309 FOREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-3351
Mailing Address - Country:US
Mailing Address - Phone:219-525-4462
Mailing Address - Fax:219-525-4175
Practice Address - Street 1:7309 FOREST RIDGE DR
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-3351
Practice Address - Country:US
Practice Address - Phone:219-525-4462
Practice Address - Fax:219-525-4175
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21405257225700000X
IN226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist