Provider Demographics
NPI:1720832009
Name:COOPER, STACIE DESHANNON (LMT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:DESHANNON
Last Name:COOPER
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 1:10169 MANZANILLA AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75217-1267
Mailing Address - Country:US
Mailing Address - Phone:469-992-4246
Mailing Address - Fax:
Practice Address - Street 1:10169 MANZANILLA AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-1267
Practice Address - Country:US
Practice Address - Phone:469-992-4246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT106974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist