Provider Demographics
NPI:1588466577
Name:PERACCA, STACY ANN (LMT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:PERACCA
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 NE 3RD AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-1752
Mailing Address - Country:US
Mailing Address - Phone:360-859-9794
Mailing Address - Fax:
Practice Address - Street 1:516 SE CHKALOV DR STE 49
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5277
Practice Address - Country:US
Practice Address - Phone:360-859-9794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61596174225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist