Provider Demographics
NPI:1588321160
Name:STEVENSON, WILLENE (LMT)
Entity type:Individual
Prefix:
First Name:WILLENE
Middle Name:
Last Name:STEVENSON
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 1:405 GAFFNEY DR APT 1
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1867
Mailing Address - Country:US
Mailing Address - Phone:718-915-4443
Mailing Address - Fax:
Practice Address - Street 1:405 GAFFNEY DR APT 1
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1867
Practice Address - Country:US
Practice Address - Phone:718-915-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029852225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist